Who Cds Imai 2004.1

WHO/CDS/IMAI/2004.
Acute Care
INTEGRATED MANAGEMENT OF ADOLESCENT AND ADULT ILLNESS

INTERIM GUIDELINES FOR FIRST-LEVEL FACILITY HEALTH WORKERS
January 2004
This is one of 4 IMAI modules relevant for HIV care: Acute Care Chronic HIV Care with ARV Therapy General Principles of Good Chronic Care Palliative Care: Symptom Management and End-of-Life Care
These are interim guidelines released for country adaptation and use to help with the emergency scale-up of antiretroviral therapy (ART) in resource-limited settings. These interim guidelines will be revised soon based on early implementation experience. Please send comments and suggestions to : imaimail@who.int. The IMAI guidelines are aimed at rst-level facility health workers and lay providers in lowresource settings. These health workers and lay providers may be working in a health centre or as part of a clinical team at the district clinic. The clinical guidelines have been simplied and systematized so that they can be used by nurses, clinical aids, and other multi-purpose health workers, working in good communication with a supervising MD/MO at the district clinic. Acute Care presents a syndromic approach to the most common adult illnesses including most opportunistic infections. Instructions are provided so the health worker knows which patients can be managed at the rst-level facility and which require referral to the district hospital or further assessment by a more senior clinician. Preparing rst-level facility health workers to treat the common, less severe opportunistic infections will allow them to stabilize many clinical stage 3 and 4 patients prior to ARV therapy without referral to the district. This module cross-references the IMAI Chronic HIV Care guidelines and Palliative Care: Symptom Management and End-of-Life Care. If these are not available, national guidelines for HIV care of adults, ART and palliative care can be substituted. Integrated Management of Adolescent and Adult Illness (IMAI) is a multi-departmental project in WHO producing guidelines and training materials for rst-level facility health workers in low-resource settings. WHO IMAI Project
World Health Organization, 2004. The World health Organization does not warrant that the information contained in this publication is complete and correct and shall not be liable for any damages incurred as a result of its use. The mention of specic companies or of certain manufacturers products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters.
Integrated Management: Acute Care

Quick Check for Emergency Signs
If laboratory tests are required, instructions for these are in the section Laboratory Tests page 105-113
Assess Acute Illness
Classify
Identify Treatments
Detailed instructions are in the section Treatment page 67 Instructions for advice and counselling and HIV testing are in the section Advise and Counsel page 95
Treatment
Consider HIVRelated Illness
Advise and Counsel
Prevention: Screening and Prophylaxis
Follow-up Care for Acute Illness
Link with Chronic HIV Care
Index
Quick Check for Emergency Signs Assess Acute Illness/Classify/Identify Treatments
Check in all patients: Ask: Cough or dicult breathing? ...............................................16-17 Check for undernutrition and anaemia ...........................................18-19 Mouth/throat problem .......................20-22 Ask about pain ............................................. 20 Ask about medications ............................. 20
10-15 16
Respond to volunteered problems or observed signs: Fever ..........................................................24-26 Diarrhoea .................................................28-30 Genito-urinary symptoms or lower abdominal pain in: woman............................................32-35 man ..................................................36-37 Genital or anal sore or ulcer ..............38-39 Skin problem or lump .........................40-45 Headache or neurological problem ....................................................46-48 Mental problem .....................................50-52 Assess and treat other problems ........... 52
Consider HIV-related Illness Prevention: Routine Screening and Prophylaxis

(for both Acute and Chronic Care patients) Advise use of insecticide-treated bednet Educate on HIV Counsel on safer sex Oer HIV testing and counselling Oer family planning Counsel to stop smoking Counsel to reduce or quit alcohol Exercises, lifting skills to prevent low-back pain Do BP screening yearly Also for women and girls of childbearing age: Tetanus Toxoid (TT) immunization If pregnant, link to antenatal care Special prevention for adolescents
53 57

Pneumonia .................................................... 62 TB sputums ................................................... 63 Fever ............................................................... 64 Persistent diarrhoea .................................. 64 Oral or oesophageal candida ................. 64 Anogenital ulcer .......................................... 65
61
Urethritis ........................................................ 65 Candida vaginitis ........................................ 65 Bladder infection ........................................ 66 Menstrual problem .................................... 66 PID .................................................................... 66 BV or trichomonas vaginitis .................... 66
Treatment
IV/IM drugs: benzathine PCN ........................................... 69 glucose ........................................................... 69 IM antimalarial ............................................. 70 diazepam IV or rectally ............................. 71 IV/IM antibiotic ............................................ 73 Metered dose inhaler: salbutamol..................................................... 74 Oral drugs Oral antibiotics............................................. 76 GC/chlamydia antibiotics ......................... 78 metronidazole .............................................. 79 Oral antimalarial .......................................... 80 paracetamol .................................................. 80 albendazole/mebendazole ..................... 81 prednisone .................................................... 81 amitriptyline ................................................. 82 haloperidol .................................................... 83 nystatin ........................................................... 84
67
See IMAI Quick Check and Emergency Treatment module for instructions on: Manage airway Insert IV, rapid uids Insert IV, slow uids Recovery position Classify/treat wheezing epinephrine
Antiseptic ....................................................... 84 aciclovir .......................................................... 85 uconazole .................................................... 85 podophyllin................................................... 85 Treat scabies ................................................. 86 Symptom control for cough/cold/ bronchitis ....................................................... 87 iron/folate ...................................................... 87 Fluid plans A/B/C for diarrhoea .......88-91 Refer urgently to hospital ........................ 92
Advise and Counsel

Provide key information on HIV......96-97 HIV testing and counselling .............98-99 Implications of test result ................... 100 Disclosure, involving partner.............. 101 Counsel on safer sex .............................. 102 Educate/counsel on STI ........................ 103 Use brief intervention guidelines for: Tobacco use Hazardous alcohol use Physical inactivity Poor diet
95
Laboratory Tests
(some may be available only at health centre level) Collect sputums for TB .......................... 106 TB SuspectsRegister .......................... 108 TB Laboratory forms .............................. 109 RPR (syphilis) testing.............................. 112
105
Insert instructions for lab tests which can be performed in clinic: Haemoglobin Urine dipstick for sugar or protein Blood sugar by dipstick Malaria dipstick or smear Rapid test for HIV (with informed consent and counselling)
Recording Form/Desk Aid
114-117 5
Steps to Use the IMAI Acute Care Module

Quick Check for Emergency Signs Assess Acute Illness Do the Quick Check for Emergency Signsif any positive sign, call for help and begin providing the emergency treatment. Ask: what is your problem? Why did you come for this consultation? Prompt any other problems?
Determine if patient has acute illness or is here for follow-up. Circle this on recording form (p. 114). How old are you? If woman of childbearing age, are you pregnant? (She will also need to be managed using the antenatal guidelinescircle this on the recording form). In all patients: Ask: Cough or dicult breathing? (16-17) Check for undernutrition and anaemia. (18-19) Look in the mouth (and respond to volunteered mouth/throat problems). (20-22) Ask about pain. If patient is in pain, grade the pain, determine location and consider cause. Manage pain using the Palliative Care guidelines. Ask: Are you taking any medications? Respond to volunteered problems or observed signs. Mark with an X on the recording form all the main symptoms the patient has.
You will need to do the assessment for any of these symptoms if volunteered or observed: Fever (24-26) Diarrhoea (28-30) Genito-urinary symptoms or lower abdominal pain in: - woman (32-35) - man (36-37) Genital or anal sore or ulcer (38-39) Skin problem or lump (40-45) Headache or neurological problem or painful feet (46-47) Mental problem (50-52)use this page if patient complains of or appears depressed or anxious or sad or fatigued or has alcohol problem or recurrent multiple complaints. Remember to use this page. If you have a doubt, use it. Assess and treat other problems. Use national and other existing guidelines for other problems that are not included in the Acute Care module. If laboratory tests are required, instructions for these are in the section Laboratory Tests at the end of the module (p. 105). Classify Classify using the IMAI acute care algorithm, following the 3 rules:
1. Use all classication tables where the patient ts the description in the arrow. 2. Start at the top of the classication table. Decide if the patients signs t the signs in the rst column. If not, go down to next row. 3. Once you nd a row/classicationSTOP! Use only one row in each classication table (once you nd the row where the signs match, do not go down any further, even if the patient has signs that also t into other, lower rows/classications. Then record all classications on the recording form. Remember that there is often more than one.
Identify Treatments
Read the treatments for each classication you have chosen. List these. Treatment Advise and Counsel
The detailed treatment instructions are in the section called Treatment. Instructions for patient education, support and counselling are in Advise and Counsel, including how to suggest HIV testing and counselling.
Consider HIVRelated Illness
If it advises you to Consider HIV-related illness, circle this on the recording form and use this section.
If the patient is HIV+, also use the Chronic HIV Care guidelines, for chronic care, prevention and support. If the treatment list advises sputums for TB, note this on the recording form and send sputums. Prevention: Routine Screening and Prophylaxis. Prevention: Screening and Prophylaxis Remember that for all patients you need to also consider what Prevention and Prophylaxis are required (circle on the recording form).
Quick Check for Emergency Care

then
Assess Acute Illness/ Classify/Identify Treatments
Quick Check for Emergency Signs
Use this chart for rapid triage assessment for all patients. Then use the Acute Care guidelines. If trauma or psychiatric emergency, see Quick Check module.
Quick check for emergency signs (medical) (Consider all signs) FIRST ASSESS: AIRWAY AND BREATHING
Appears obstructed or Central cyanosis (blue mucosa) or Severe respiratory distress
Check for obstruction, wheezing and pulmonary oedema
THEN ASSESS: CIRCULATION (SHOCK)

Cold skin or Weak and fast pulse or Capillary rell longer than 2 seconds
Check BP and pulse. Look for bleeding. Ask: Have you had diarrhoea?
10
TREATMENT
If obstructed breathing, manage the airway. Prop patient up or help to assume position for best breathing. If wheezing, treat urgently (p. 74). If pulmonary oedema, consider furosemide if known heart disease. Give appropriate IV/IM antibiotics pre-referral. Refer urgently to hospital. If trauma see Quick Check module.
This patient may be in shock: If systolic BP < 90 mmHg or pulse >110 per minute: - Insert IV and give uids rapidly. If not able to insert peripheral IV, use alternative. - Position with legs higher than chest. - Keep warm (cover). - Consider sepsisgive appropriate IV/IM antibiotics. - Refer urgently to hospital. If diarrhoea: assess for dehydration and follow plan C (this patient may not need referral after rehydration). If severe undernutrition, see p. 18. If melena or vomiting blood, manage as on page Q12 and refer to hospital. If haemoptysis > 50 ml, insert IV and refer to hospital.
11
UNCONSCIOUS/CONVULSING
Convulsing (now or recently), or Unconscious If unconscious, ask relative: has there been a recent convulsion?
Measure BP and temperature
PAIN
If chest pain What type of pain?
Check BP, pulse, temperature, age
If severe abdominal pain: Is abdomen hard?
Check BP, pulse, temperature
If neck pain or severe headache: Has there been any trauma?
Check BP Ask patient to move neckdo not passively move
12
For all: Protect from fall or injury. Get help. Assist into recovery position (wait until convulsion ends). Insert IV and give uids slowly. Give appropriate IM/IV antibiotics. Give IM antimalarial. Give glucose*. Refer urgently to hospital after giving pre-referral care. Do not leave alone. If convulsing, also: Give diazepam IV or rectally. Continue diazepam en route as needed. If unconscious: Manage the airway. Assess possibility of poisoning, alcohol or substance abuse.
If trauma, use the Quick Check guidelines.
If age > 50, no history of trauma, and history suggests cardiac ischaemia: Give aspirin (160 or 325 mg, chewed). Refer urgently to hospital. If pleuritic pain with cough or dicult breathing, assess for pneumonia. Consider pneumothorax.
Insert IV. If hard abdomen or shock, give uids rapidly. If not, give uids slowly (30 drops/minute). Refer urgently to hospital*.
For other pain, use the Acute Care guidelines to determine cause. See the Palliative Care guidelines for management of pain.
* If high glucose, see diabetes management guidelines.
Consider meningitis and other causes of acute headache (see p. 46-48). If BP > systolic 180, refer urgently to hospital. If pain on neck movement by patient after trauma by history or exam, immobilize the neck and refer.
13
FEVER from LIFE-THREATENING CAUSE

Any fever with: - sti neck - very weak/not able to stand - lethargy - unconscious - convulsions - severe abdominal pain - respiratory distress
Any sign present measure temperature, BP
14
Insert IV. Give uids rapidly if shock or suspected sepsis. If not, give uids slowly (30 drops/minute). Give appropriate IV/IM antibiotics. Give artemether IM. (If not available, give quinine IM). Give glucose. Refer urgently to hospital.
Also consider neglected trauma with infectionsee Quick Check guidelines.
If no emergency signs, proceed immediately to
Assess Acute Illness/ Classify/Identify Treatments

Ask: what is your problem? Why did you come for this consultation? Prompt any other problems? Determine if patient has acute illness or is here for follow-up. Circle this on recording form (p. 114). How old are you? If woman of childbearing age, are you pregnant? (She will also need to be managed using the antenatal guidelinescircle this on the recording form).
15
Assess Acute Illness
In all patients: Do you have cough or dicult breathing?

IF YES, ASK:
For how long? Are you having chest pain? - If yes, is it new? Severe? Describe it. Have you had night sweats? Do you smoke? Are you on treatment for a chronic lung or heart problem or TB? Determine if patient diagnosed as asthma, emphysema or chronic bronchitis (COPD), heart failure or TB (also look in Chronic Disease Register). If not, Have you had previous episodes of cough or dicult breathing? - If recurrent: -- Do these episodes of cough or dicult breathing wake you up at night or in the early morning? -- Do these episodes occur with exercise?
LOOK AND LISTEN

Is the patient lethargic? Count the breaths in 1 minuterepeat if elevated. Look and listen for wheezing. Determine if the patient is uncomfortable lying down. Measure temperature. If not able to walk unaided or appears ill, also: Count the pulse. Measure BP.
Classify in all with cough
AGE
5-12 years 13 years or more
FAST BREATHING IS:

30 breaths per minute or more 20 breaths per minute or more
VERY FAST BREATHING IS:

40 breaths per minute 30 breaths per minute or more
16
Classify
Identify Treatments
Use this classication table in all with cough or dicult breathing: SIGNS:
One or more of the following signs:
Very fast breathing or High fever (38C or above) or Pulse 120 or more or Lethargy or Not able to walk unaided or Uncomfortable lying down or Severe chest pain
CLASSIFY AS:
SEVERE PNEUMONIA OR VERY SEVERE DISEASE

TREATMENTS:
Position Give oxygen Give rst dose IM antibiotics If wheezing present, treat (p. 74) If severe chest pain in patient 50 years or older, use Quick Check If known heart disease and uncomfortable lying down, give furosemide Refer urgently to hospital Consider HIV-related illness (p. 54) If on ARV therapy, this could be serious drug reaction. See Chronic HIV Care guidelines
Two of the following signs: Fast breathing Night sweats Chest pain
PNEUMONIA
Give appropriate oral antibiotic Exception: if second/third trimester pregnancy, HIV clinical stage 4, or low CD4 count, give rst dose IM antibiotics and refer urgently to hospital If wheezing present, treat (p. 74) If smoking, counsel to stop smoking Consider HIV-related illness (p. 54) If on ARV treatment, this could be a serious drug reaction; consult/refer If cough > 2 weeks, send sputums for TB Advise when to return immediately Follow up in 2 days If cough > 2 weeks, send 3 sputums for TB or send the patient to district hospital for sputum testing (record in register ) If sputums sent recently previously, check register for result. If negative, refer to district hospital for assessment if a chronic lung problem has not been diagnosed If smoking, counsel to stop If wheezing, treat (p. 74) Advise when to return immediately Advise on symptom control If smoking, counsel to stop If wheezing, treat (p. 74) Advise when to return immediately
Cough or dicult breathing for more than 2 weeks, or Recurrent episodes of cough or dicult breathing which: - Wake patient at night or in the early morning or, - Occur with exercise
POSSIBLE CHRONIC LUNG OR HEART PROBLEM
Insucient signs for the above classications
NO PNEUMONIA COUGH/COLD, OR BRONCHITIS
17
Check all patients for undernutrition and anaemia

IF YES, ASK: Have you lost weight? What medications are you taking? If wasted or reported weight loss, how much has your weight changed? Ask about diet. Ask about alcohol use. % Weight loss = OldNew Old weight LOOK AND FEEL Look for visible wasting. Look for loose clothing. If present, did it t before? If wasted or reported weight loss: Weigh and calculate % weight loss. Measure mid-upper arm circumference (MUAC). Look for sunken eyes. Look for oedema of the legs. If present: Does it go up to the knees? Is it pitting? Assess for infection using the full Acute Care algorithm. Look at the palms and conjunctiva for pallor. Severe? Some? If pallor: * Count breaths in one minute. Breathless? Bleeding gums? Petechiae?
If visible wasting or weight loss
If pallor: Black stools? Blood in stools? Blood in urine? In menstruating adolescents and women: heavy menstrual periods?
If pallor
* If haemoglobin result available, classify as SEVERE ANAEMIA if haemoglobin less than 7 grams; SOME ANAEMIA if less than 10 grams.
18
Use this table if visible wasting or weight loss SIGNS:

MUAC < 160 mm or MUAC 161-185 mm plus one of the following: - Pitting edema to knees on both sides - Cannot stand - Sunken eyes Weight loss > 5% or Reported weight loss or Loose clothing which used to t
CLASSIFY AS:
SEVERE UNDERNUTRITION
TREATMENTS:
Refer for therapeutic feeding if nearby or begin community-based feeding Consider TB (send sputums if possible) Consider HIV-related illness (p. 54) Counsel on HIV testing
SIGNIFICANT WEIGHT LOSS
Treat any apparent infection If diarrhoea, manage as p. 26-28 Increase intake of energy and nutrientrich foodcounsel on nutrition Consider TB (send sputums if possible); diabetes mellitus (dipstick urine for glucose); excess alcohol; substance abuse Consider diabetes mellitus if weight loss accompanied by polyuria or increased thirst (dipstick urine for glucose) Consider HIV-related Illness (p. 54) Counsel on HIV testing Follow up in 2 weeks Advise on nutrition
* Weight loss < 5%
NO SIGNIFICANT WEIGHT LOSS
Use this table if pallor

Severe palmar and conjunctival pallor or Any pallor with: - 30 or more breaths per minute or - Breathless at rest or Bleeding gums or petechiae or Black stools or blood in stools Palmar or conjunctival pallor
SEVERE ANAEMIA Refer to hospital OR OTHER SEVERE If not able to refer, treat as below and follow up in 1 week PROBLEM
Consider HIV-related illness (p. 55) Consider ARV side eect (especially ZDV) or cotrimoxaxole side eects (see Chronic HIV Care) Consider malaria if low immunity or increased exposure (see p. 24)
SOME ANAEMIA
Consider HIV-related illness (p. 54)

ARV drugs, especially ZDV, can cause anaemia (see Chronic HIV Care) Consider malaria if low immunity or increased exposure (see p. 24) Give twice daily iron/folate Counsel on adherence Advise to eat locally available foods rich in iron Give albendazole if none in last 6 months If heavy menstrual periodssee p. 35 Follow up in 1 month
19
Look in the mouth of all patients and respond to any complaint of mouth or throat problem
If you see any abnormality or patient complains of a mouth or throat problem, ASK:
LOOK
If patient has white or red patches
Do you have pain? - If yes, where ? When does this occur? (When swallowing? When hot or cold food?) Do you have problems swallowing? Do you have problems chewing? Are you able to eat? What medications are you taking?
Look in mouth for: White patches - If yes, can they be removed? Ulcer - If yes, are they deep or extensive? Tooth cavities Loss of tooth substance Bleeding from gums Swelling of gums Gum bubble Pus Dark lumps Look at throat for: White exudate Abscess Look for swelling over jaw Feel for enlarged lymph nodes in neck If patient complains of tooth pain, does tapping or moving the tooth cause pain?
Classify
If sore throat without mouth problem
If mouth ulcer or gum problem, page 22 If tooth problem or jaw pain or swelling, page 22
20
If patient has white or red patches SIGNS:

Not able to swallow
CLASSIFY AS:
SEVERE OESOPHAGEAL THRUSH
TREATMENTS:
Refer to hospital If not able to refer, give uconazole Give uconazole Give oral care Follow up in 2 days Consider HIV-related illness (p. 54)
Pain or diculty swallowing
OESOPHAGEAL THRUSH ORAL THRUSH
White patches in mouth and Can be scraped o Painless White patches on side of tongue and Cannot be scraped o
Give nystatin or miconazole gum patch Give oral care Consider HIV-related illness (p. 54) No treatment needed Consider HIV-related illness (p. 54) Instruct in oral care
ORAL (HAIRY) LEUKOPLAKIA
Use this table if sore throat without mouth problem

Not able to swallow or Abscess TONSILLITIS Refer urgently to hospital Give benzathine penicillin Give benzathine penicillin Soothe throat with a safe remedy Give paracetamol for pain Return if not better Soothe throat with a safe remedy Give paracetamol for pain
Enlarged lymph node on neck and White exudate on throat
STREPTOCOCCAL SORE THROAT
Only 1 or no signs in the above row present
NON-STREP SORE THROAT
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21
Use this table if mouth ulcer or gum problem: SIGNS:

Deep or extensive ulcers of mouth or gums or Not able to eat
CLASSIFY AS:
TREATMENTS:
SEVERE GUM/ Refer urgently to hospital unless only palliative care planned MOUTH INFECTION Trial aciclovir Start metronidazole if referral not possible or distant Consider HIV-related illness (p. 54) If on ARV therapy, this may be drug reaction (see Chronic HIV Care) GUM/MOUTH ULCERS Show patient/family how to clean with saline or peroxide or sodium bicarbonate If lips or anterior gums, give aciclovir Instruct in oral care Consider HIV-related illness (p. 54) If on ARV, or started cotrimoxazole or INH prophylaxis within last month, this may be drug reaction, especially if patient also has new skin rash (see Chronic HIV Care; refer, stop drugs) See Palliative Care for pain relief Follow up in 7 days Instruct in oral care
Ulcers of mouth or gums
Bleeding from gums (in absence of other bleeding or other symptoms) Swollen gums
GUM DISEASE
Use this table if tooth problem or jaw pain or swelling:

Constant pain with: - Swollen face or gum near tooth or - Gum bubble or Tooth pain when tapped or moved Pain when eating hot or cold food or Visible tooth cavities or Loss of tooth substance TOOTH DECAY DENTAL ABSCESS If fever, give antibiotics Lance abscess or pull tooth Refer urgently to dental assistant if not able to do so Consider sinusitis (do not pull teeth if this is cause) Place gauze with oil of clove Refer to dentist for care or pull tooth
22
In all patients, ask: Are you in pain?

If patient is in pain, grade the pain, determine location and consider cause. Manage pain using the Palliative Care guidelines.
In all patients, ask: Are you taking any medications?

It is particularly important to consider toxicity from ARV drugs and immune reconstruction syndrome (in rst 2-3 months of antiretroviral therapy (ART) when evaluating new signs and symptoms.
Now respond to:
Volunteered Problems or Observed Signs
23
Does the patient have feverby history of recent fever (within 48 hours) or feels hot or temperature 37.5C or above?
IF YES, ASK:
How long have you had a fever? Any other problem? What medications have you taken? Determine if antimalarial and for how long. Decide malaria risk: High Low No Where do you usually live? Have you recently travelled to a malaria area? If woman of childbearing age: - Are you pregnant? Is an epidemic of malaria occurring? HIV clinical stage 3 or 4.
LOOK AND FEEL

Look at the patients neurological condition. Is the patient: - Lethargic? - Confused? - Agitated? Count the breaths in one minute. Use table on p.16 to determine if fast breathing. - If fast breathing , is it deep? Check if able to drink. Feel for sti neck. Check if able to walk unaided. Skin rash? Look for apparent cause of fever (assess all symptoms in this Acute Care algorithm and consider whether this could be related to ARV treatmentsee Chronic HIV Care). Do malaria dipstick or smear if available.
Patient has high malaria risk
Classify
If low immunity (with malaria transmission): Pregnant. Child less than 10 years if there is intense or HIGH moderate malaria. MALARIA RISK Stage 3 or 4 HIV infection (see Chronic HIV Care module). Or increased exposure: Epidemic of malaria is occurring. Moved to or visited area with intense or moderate malaria. If high immunity: Adolescent or adult who has lived since childhood LOW in area with intense or moderate malaria. MALARIA Or low exposure: RISK Low malaria transmission and no travel to higher transmission area. NO MALARIA If no malaria transmission and RISK No travel to area with malaria transmission.
Patient has low malaria risk
Patient has no malaria risk, p. 26
24
Use this table if fever with high malaria risk: SIGNS:

One or more of the following signs: Confusion, agitation, lethargy or Fast and deep breathing or Not able to walk unaided or Not able to drink or Sti neck Fever or history of fever
CLASSIFY:
VERY SEVERE FEBRILE DISEASE

TREATMENTS:
Give IM quinine or artemether Give rst dose IM antibiotics Give glucose Refer urgently to hospital
MALARIA
Give appropriate oral antimalarial Determine whether adequate treatment already given with the rst-line antimalarial within 1 weekif yes, an eective secondline antimalarial is required Look for other apparent cause Consider HIV-related illness (p. 54) If fever for 7 days or more, consider TB (send sputums/refer) Follow up in 3 days if still febrile
Use this table if fever with low malaria risk:

Confusion, agitation, lethargy or Not able to drink or Not able to walk unaided or Sti neck or Severe respiratory distress Fever or history of fever and No new rash and No other apparent cause of fever or Dipstick or smear positive for malaria
VERY SEVERE FEBRILE DISEASE
Give IM quinine or artemether Give rst dose IM antibiotics Give glucose Refer urgently to hospital
MALARIA
Give appropriate oral antimalarial Determine whether adequate treatment already given with the rst-line antimalarial within 1 weekif yes, an eective second-line antimalarial is required Consider fever related to ARV use (see Chronic HIV Care) Follow up in 3 days if still febrile Treat according to the apparent cause (Exception: Also give IM antimalarial if patient is classied as SEVERE PNEUMONIA) Consider HIV related illness if unexplained fever for > 30 days (p. 54) Consider fever related to ARV use (see Chronic HIV Care) If no apparent cause and fever for 7 days or more, send sputums for TB and refer to hospital for assessment
Other apparent cause of fever or New rash or Dipstick or smear negative for malaria
FEVER MALARIA UNLIKELY
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25
Use this table if fever with no malaria risk: SIGNS:

Confusion, agitation, lethargy or Not able to drink or Not able to walk unaided or Sti neck Fever for 7 days or more
CLASSIFY AS:
TREATMENTS:
VERY SEVERE FEBRILE Give rst dose IM antibiotics DISEASE
Give glucose Refer urgently to hospital Use this table if fever with no malaria risk: Treat according to apparent cause Consider TB (send sputums/refer) If no apparent cause, refer to hospital for assessment Consider HIV related illness if unexplained fever for > 7 days (p. 54) Consider fever related to ARV use (see Chronic HIV Care) Follow up in 2-3 days if fever persists Treat according to apparent cause
PERSISTENT FEVER
None of the above
SIMPLE FEVER
26
NOTES:
27
If the patient has diarrhoea

IF YES, ASK: For how long? - If more than 14 days, have you been treated before for persistent diarrhoea? - If yes, with what? When? Is there blood in the stool? LOOK AND FEEL Is the patient lethargic or unconscious? Look for sunken eyes. Is the patient: - Not able to drink or Classify drinking poorly? DIARRHOEA - Drinking eagerly, thirsty? Pinch the skin of the inside of the forearm. Does it go back: - Very slowly (longer than 2 seconds)? - Slowly?
Classify all patients with diarrhoea for DEHYDRATION
If diarrhoea for 14 days or more and no blood, page 29 And if blood in stool, page 29
28
Use this table in all patients with diarrhoea: SIGNS:

Two of the following signs: Lethargic or unconscious Sunken eyes Not able to drink or drinking poorly Skin pinch goes back very slowly
CLASSIFY AS: SEVERE DEHYDRATION
TREATMENTS:
If no other severe classication, give uid for severe dehydration (Plan C on p. 90) then reassess (this patient may not require referral) or If another severe classication: Refer URGENTLY to hospital after initial IV hydration or, if not possible, with frequent sips of ORS on the way If there is cholera in your area, give appropriate antibiotic for cholera (according to sensitivity data)
Two of the following signs: Sunken eyes Drinks eagerly, thirsty Skin pinch goes back slowly Not enough signs to classify as some or severe dehydration
SOME DEHYDRATION
Give uid and food for some dehydration (Plan B on p. 89) Advise when to return immediately Follow up in 5 days if not improving
NO DEHYDRATION
Give uid and food to treat diarrhoea at home (Plan A on p. 88) Advise when to return immediately Follow up in 5 days if not improving
go to next page
29
Also use this table if diarrhoea for 14 days or more and no blood SIGNS:
Some or severe dehydration present
CLASSIFY AS:
SEVERE PERSISTENT DIARRHOEA
TREATMENTS:
Give uids for dehydration (Plan B or C on p. 89-90) before referral, then reassess (this patient may not require referral) If signs of dehydration persist or another severe classication, refer urgently to hospital Give appropriate empirical treatment, depending on recent treatment and HIV status Consider HIV-related illness (p. 56) If on ARV treatment, this could be drug side eect (see Chronic HIV Care) Give supportive care for persistent diarrhoea (see Palliative Care) Give nutritional advice and support Follow up in 5 days (explain when to refer)
No dehydration
PERSISTENT DIARRHOEA
Also use this table if blood in stool:

Blood in the stool
DYSENTERY
Treat for 5 days with an oral antibiotic recommended for Shigella in your area Advise when to return immediately Follow up in 2 days
30
NOTES:
31
If female patient complains of genito-urinary symptoms or lower abdominal pain

For adult non-pregnant woman or adolescent, use this page. For pregnant woman, use antenatal guidelines. For a man, use page 36. IF YES, ASK:
What is the problem? What medications are you taking? Do you have: Burning or pain on urination? Increased frequency of urination? Sore in your genital area? An abnormal vaginal discharge? - If yes, does it itch? Any bleeding on sexual contact? Has your partner had any problem? - If partner is present, ask him about urethral discharge or sores. When was your last menstrual period? - If missed period: Do you think you might be pregnant? Are you using contraception? If yes, which one? Are you interested in contraception? If yes, use Family Planning guidelines. Do you have very painful menstrual cramps? Have you had very heavy or irregular periods? - If yes: -- Is the problem new? --How many days does your bleeding last? --How often do you change pads or tampons?
LOOK AND FEEL

Feel for abdominal tenderness. If tenderness: - Is there rebound? - Is there guarding? - Can you feel a mass? - Are bowel sounds present? - Measure temperature. - Measure pulse. Perform external exam, look for large amount of vaginal discharge (if only small amount white discharge in adolescent, this is usually normal). Look for anal or genital ulcer. If present, also use p. 38. Feel for enlarged inguinal lymph mode If present, also use p. 38. If you are able to do bimanual exam, feel for cervical motion tenderness If burning or pain on urination or complaining for back or ank pain: - Percuss ank for tenderness.
If lower abdominal pain (other than menstrual cramps)
Classify
If abnormal vaginal discharge, page 34 Burning or pain on urination or ank pain, page 34 If menstrual pain or missed period or bleeding irregular or very heavy periods, page 35
If suspect gonorrhoea/ chlamydia infection based on any of these factors
* If not able to refer, give ampicillin and metronidazole for possible appendicitis.
32
Use this table in all women with lower abdominal pain (other than menstrual cramps) SIGNS:
Abdominal tenderness with: Fever > 38 C or Rebound or Guarding or Mass or Absent bowel sounds or Not able to drink or Pulse > 110 or Recent missed period or abnormal bleeding Lower abdominal tenderness or Cervical motion tenderness
CLASSIFY AS:
SEVERE OR SURGICAL ABDOMINAL PROBLEM
TREATMENTS:
Give appropriate IV/IM antibiotics Give patient nothing by mouth (NPO) Insert IV Refer URGENTLY to hospital* If bleeding, follow other guidelines for bleeding in early pregnancy; consider ectopic pregnancy Give ciprooxacin plus doxycycline plus metronidazole Follow up in 2 days if not improved; follow up all at 7 days Promote/provide condoms Oer HIV/STI counselling and HIV and RPR testing Treat partner for GC/ chlamydia Abstain from sex during treatment If diarrhoea, see page 28 If constipation, advise remedies (see Palliative Care) Return if not improved
PID (pelvic inammatory disease)
Abdomen soft and none of the above signs
GASTRO-ENTERITIS OR OTHER GI OR GYN PROBLEM
Use this table if suspect gonorrhoea/chlamydia based on any of these factors

Sex worker or Bleeding on sexual contact or Partner with urethral discharge or burning on urination or Any woman who thinks she may have STI
POSSIBLE GONORRHOEA/ CHLAMYDIA INFECTION
Treat woman and partner with antibiotics for possible GC/chlamydia infection Promote/provide condoms Consider HIV-related illness; oer HIV/STI counselling and HIV and RPR testing Advise to use condoms Follow up in 7 days if symptoms persist
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33
Use this table in all women with abnormal vaginal discharge SIGNS:
Itching or Curd-like vaginal discharge None of the above BACTERIAL VAGINOSIS (BV) OR TRICHOMONIASIS
CLASSIFY AS:
CANDIDA VAGINITIS
TREATMENTS:
Treat with nystatin Return if not resolved Consider HIV-related illness if recurrent (p. 54) Give metronidazole 2 grams at once Return if not resolved
Use this table in all women with burning or pain on urination or ank pain
Flank pain or Fever KIDNEY INFECTION If systemically ill: Give appropriate IM antibiotics Refer URGENTLY to hospital Also refer if on indinavir (an ARV drug) If not: Give appropriate oral antibiotics Follow up next day Give appropriate oral antibiotics Increase uids Follow up in 2 days if not improved Treat for vaginitis if abnormal discharge Dipstick urine if possible
Burning or pain on urination and Frequency and No abnormal vaginal discharge None of the above
BLADDER INFECTION
BLADDER INFECTION UNLIKELY
34
Use this table in all women with menstrual pain or missed period or bleeding irregular or very heavy period SIGNS:
Irregular bleeding and Sexually active or Any bleeding in known pregnancy Missed period and Sexually active and No contraceptive implant Not pregnant with: New irregular menstrual bleeding or Soaks more than 6 pads each of 3 days (with or without pain)
CLASSIFY AS:
PREGNANCYRELATED BLEEDING OR ABORTION
TREATMENTS:
Follow guidelines for vaginal bleeding in pregnancy (e.g. IMPAC *)
POSSIBLE PREGNANCY
Discuss plans for pregnancy If she wishes to continue pregnancy, use guidelines for antenatal care (e.g. IMPAC*) Consider contraceptive use and need (see Family Planning guidelines): - If contraception desired, suggest oral contraceptive pill - IUD in the rst 6 months and long acting injectable contraceptive can cause heavy bleeding; combined contraceptive pills or the mini-pill can cause spotting or bleeding between periods If on ART, consider withdrawal bleeding from drug interaction (see Chronic HIV Care module) Refer for gynaecological assessment if unusual or suspicious in older women If painful menstrual cramps or to reduce bleeding, give ibuprofen (not aspirin) Follow up in 2 weeks
IRREGULAR MENSES OR VERY HEAVY PERIODS (MENORRHAGIA)
Only painful menstrual cramps
DYSMENORRHOEA
If she also wants contraception, suggest oral contraceptive pill Give ibuprofen (aspirin or paracetamol may be substituted but are less eective)
* WHO Integrated Management of Pregnancy and Childbirth (IMPAC)
35
If male patient complains of genito-urinary symptoms or lower abdominal pain (Use this page for men)
IF YES, ASK: What is your problem? Do you have discharge from your urethra? - If yes, for how long? If this is a persistent or recurrent problem, see follow-up box. Do you have burning or pain on urination? - Do you have pain in your scrotum? - If yes, have you had any trauma there? Do you have sore(s)? LOOK AND FEEL Perform genital exam. Look for scrotal swelling. Feel for tenderness. Look for ulcer: - If present, also use p. 38. Look for urethral discharge. Feel for rotated or elevated testis. - If abdominal pain, feel for tenderness. - If tenderness: -- Is there rebound? -- Is there guarding? -- Can you feel a mass? -- Are bowel sounds present? -- Measure temperature. -- Measure pulse.
If lower abdominal pain
If urethral discharge or urination problems
If scrotal swelling or tenderness
* If fever with right lower abdominal pain and referral is delayed, give ampicillin and metronidazole for possible appendicitis.
36
Use this table in men with lower abdominal pain SIGNS:

Abdominal tenderness with: Fever > 38C or Rebound or Guarding or Mass or Absent bowel sounds or Not able to drink or Pulse > 110 Abdomen soft and none of the above signs
CLASSIFY AS:
TREATMENTS:
SEVERE OR SURGICAL Give patient nothing by mouth (NPO) ABDOMINAL Insert IV PROBLEM
Give appropriate IV/IM antibiotics Refer URGENTLY to hospital*
GASTROENTERITIS OR If diarrhoea, see p. 29 OTHER GI PROBLEM If constipation, advise
remedies Return if not improved
Use this table in men with urethral discharge or urination problem

Not able to urinate and Bladder distended Urethral discharge or Burning on urination
PROSTATIC OBSTRUCTION POSSIBLE GONORRHOEA/ CHLAMYDIA INFECTION
Pass urinary catheter if trained Refer to hospital Treat patient and partner with antibiotics for possible GC/chlamydia infection Promote/provide condoms Return if worse or not improved within 1 week Oer HIV/STI counselling and HIV and RPR testing Consider HIV-related illness (p. 54) Partner management
Use this table in all men with scrotal swelling or tenderness

Testis rotated or elevated or History of trauma Swelling or tenderness (without the above signs)
POSSIBLE TORSION POSSIBLE GONORRHOEA/ CHLAMYDIA INFECTION
Refer URGENTLY to hospital for surgical evaluation Treat patient and partner with antibiotics for possible GC/chlamydia infection Promote/provide condoms Follow up in 7 days; return earlier if worse Oer HIV counselling and testing Consider HIV-related illness (p. 54)
37
If the patient complains of a genital or anal sore, ulcer or warts

IF YES, ASK: Are these new? If not, how often have you had them? Have there been vesicles before? LOOK AND FEEL Look for anogenital sores. If present, are there vesicles? Look for warts. Look/feel for enlarged lymph node in inguinal area. If present: Is it painful?
* For haemorrhoids/anal ssure management (see Palliative Care)
If anogenital ulcer
If painful inguinal node
If warts
38
SIGNS:
Only vesicles present
CLASSIFY AS:
GENITAL HERPES

TREATMENTS:
Keep clean and dry Give aciclovir, if available Promote/provide condoms Educate on STI, HIV and risk reduction, oer HIV testing and counselling and RPR testing Consider HIV-related illness if ulcerations present > 1 month (p. 54) Follow up in 7 days if sores not fully healed, earlier if worse Give benzathine penicillin for syphilis Give aciclovir if history of recurrent vesicles Give ciprooxacin for chancroid Promote and provide condoms Consider HIV-related illness (p. 54); oer HIV testing and counselling Educate on STI, HIV and risk reduction Treat all partners within last 3 months Follow up in 7 days
Sore or ulcer
GENITAL ULCER
Enlarged and painful inguinal node
INGUINAL BUBO
Give ciprooxacin for 3 days andif no ulcer doxycycline for 14 days; also treat partner If uctuant, aspirate through healthy skin; do not incise Provide/promote condoms Partner management Consider HIV-related illness; oer HIV testing and counselling, and RPR testing Educate on STI, HIV and risk reduction Follow up in 7 days Apply podophyllin Consider HIV-related illness Oer HIV testing and counselling Educate on STI, HIV and risk reduction
Warts
GENITAL WARTS
39
If patient has a skin problem or lump

IF YES, ASK: Do you have a sore or skin problem or lump? If yes, where is it? Does it itch? Does it hurt? Duration? Discharge? Do other members of the family have the same problem? Are you taking any medication? If on ARV therapy, skin rash could be a serious side eect. See Chronic HIV Care. LOOK AND FEEL Are there lesions? Where? How many? Are they infected (red, tender, warm, pus or crusts)? Feel for uctuance. Are they tender? Feel for lymph nodes. Are they tender?
If enlarged lymph nodes or mass
Is it infected? Consider this in all skin lesions.
Look/feel for lumps. If painful inguinal node or ano-genital ulcer or vesicles, see p. 39 If dark lumps, consider HIV-related illness, see p. 54
If red, tender, warm, pus or crusts (infected skin lesion)
If itching skin problem, use p. 42 If skin sores, blisters or pustules, use p. 43 If skin patch with no symptoms or loss of feeling, use p. 44
40
Use this table if enlarged lymph nodes or mass SIGNS:

Size > 4 cm or Fluctuant or Hard or Fever
CLASSIFY AS:
SUSPICIOUS LYMPH NODE OR MASS
TREATMENTS:
Refer for diagnostic work at district hospital Consider TB Give oral antibiotic Follow up in 1 week
Nearby infection which could explain lymph node or Red streaks > 3 lymph node groups with: - > 1 node - > 1 cm - > 1 month duration - No local infection to explain
REACTIVE LYMPHADENOPATHY PERSISTENT GENERALIZED LYMPHADENOPATHY
Do RPR test for syphilis if none recently Consider HIV-related illness (p. 54)
Is it infected? Ask this in all skin lesions. If yes, also use the infection classication table below.
Use this table if lesion red, tender, warm, pus or crusts (infected skin lesion)
Fever or Systemically unwell or Infection extends to muscle
SEVERE SOFT TISSUE OR Refer to hospital MUSCLE INFECTION Start IV/IM antibiotics (If
not available, give oral cloxacillin) Consider HIV-related illness
Size > 4 cm or Red streaks or Tender nodes or Multiple abscesses
SOFT TISSUE INFECTION Start cloxacillin OR FOLLICULITIS Drain pus if uctuance

Elevate the limb Follow up next day
Only red, tender, warm, pus or crustsnone of the signs in the pink or yellow row
IMPETIGO OR MINOR ABSCESS
Clean sores with antiseptic Drain pus if uctuance Follow up in 2 days
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41
Use this table if itching skin problems Scabies Papular itching rash (prurigo)
Itching rash with small papules and scratch marks. Dark spots with pale centers.
Eczema
Ringworm (tinea)
Pale, round, bald scaling patches on scalp or round patches with thick edge on body or web of feet.
Dry itchy skin (xerosis)

Dry and rough skin, sometimes with ne cracks.
Rash and excoriations on torso; burrows in webspace and wrist; face spared.
Wet, oozing sores or excoriated, thick patches.
Manage with anti-scabies medication. Treat itching. If persistent, consider HIVrelated illness (p. 86).
Treat itching. Oral antihistamines. Consider HIVrelated illness (p. 54).
Soak sores with clean water to remove crusts (no soap). Dry the skin gently. Short term: use topical steroid cream (not on face). Treat itching.
Whitelds ointment (or other antifungal cream) if few patches. If extensive, give ketoconazole or griseofulvin. If in hairline, shave hair. Treat itching. Consider HIVrelated illness (p. 54).
Emollient lotion or calamine lotion, continue if eective. Locally eective remedies. Give antihistamine. Consider HIVrelated illness (p. 54).
Is it infected? Ask this in all skin lesions. If yes, also use the infection classication table on page 41.
42
Illustrations courtesy of the Hesperian Foundation, Where There Is No Doctor and Where Women Have No Doctor.
Use this table if blister, sore or pustules

Contact dermatitis
Limited to area in contact with problem substance Early: blistering and red. Later: thick, dry, scaly.
Herpes zoster
Vesicles in one area on one side of body plus intense pain; or scars plus shooting pain.
Herpes simplex
Vesicular lesion or sores, also involving lips and/or mouthsee page 22.
Drug reaction
Generalized red, widespread with small bumps or blisters; or one or more dark skin areas (xed drug reaction).
Impetigo or folliculitis
Red, tender, warm crusts or small lesions.
Hydrocortisone Keep clean and dry; use local 1% ointment antiseptic. or cream. If eye involved If severe or any suspicion reaction encephalitis, give with blisters, aciclovir 800 mg exudate or oedema, give 5 times daily x 7 prednisone. days. Find and Pain relief remove cause. analgesics and low dose amitriptiline. Oer HIV counselling and testing. Consider HIV-related illness. Discuss the possible HIV illness. (p. 54). Follow up in 7 days if sores not fully healed, earlier if worse.
If ulceration for > 30 days, consider HIV related illness. If rst or severe ulceration, give aciclovir.
Stop medications. Give oral antihistamine. If peeling rash with involvement of eyes and/or mouthrefer urgently to hospital. Give prednisone if severe reaction or any diculty breathing.
See infection table on p. 41.
43
Use this table if skin rash with no or few symptoms No or few symptoms Leprosy
Skin patch(es) with: No sensation to light touch, heat or pain. Any location. Pale or reddish or coppercolored. Flat or raised or nodular. Chronic (> 6 months). Not red or itchy or scaling. Ketoconazole shampoo (alternative: keratolytic shampoo with salicylic acid or selenium sulde or coal tar). Repeated treatment may be needed. If severe, topical steroids or trial ketoconazole. Consider HIV-related illness (p. 54). Coal tar ointment 5% in salicylic acid 2%. Expose to sunlight 3060 minutes/day.
Seborrhoea
Psoriasis
Greasy scales and redness, on Red, thickened and scaling central face, scalp, body folds, patches (may itch in some). Often on knees and and chest. elbows, scalp and hairline, lower back.
Treat with leprosy MDT (multidrug therapy) if no MDT in past (see Chronic Care module or other leprosy guidelines).
44
See Adolescent Job Aid for acne. If on ARV therapy, see Chronic HIV Care module and consult. Skin reactions are potentially serious. See other guidelines for: Tropical ulcer. Other skin problems not included here. List it as other skin problem if you dont know what it is. Consult.
45
If patient has a headache or neurological problem

IF YES, ASK: Do you have weakness in any part of your body? Have you had an accident or injury involving your head recently? Have you had a convulsion? Assess alcohol/drug use. Are you taking any medications? Ask family: - Has the patients behaviour changed? - Is there a memory problem? - Is patient confused? If confused: - When did it start? - Determine if patient is oriented to place and time. If headache: - For how long? - Visual defects? - Vomiting? - On one side? - Prior diagnosis of migraine? - In HIV patient, new or unusual headache? LOOK AND FEEL Assess for focal neurological problems: Look at face-accid on one side? Problem walking? Problem talking? Problem moving eyes? Flaccid arms or legs? - If yes, loss of strength? Feel for sti neck. Measure BP. Is patient confused? If patient reports weakness, test strength. If headache, feel for sinus tenderness. If confused or disoriented, look for physical cause or alcohol or drug medication toxicity or withdrawal.
If painful feet or legs If acute headache or loss of body function
If delusions or bizarre thoughts, see page 50.
If cognitive problems, page 50
46
Use this table if headache or neurological problem SIGNS:

Loss of body functions or Focal neurological signs or Sti neck or Acute confusion or Recent head trauma or Recent convulsion or Behavioural changes or Diastolic BP > 120 or Prolonged headache (> 2 weeks) or In known HIV patient: - Any new unusual headache or - Persistent headache more than 1 week Tenderness over sinuses
CLASSIFY AS:
SERIOUS NEUROLOGICAL PROBLEM
TREATMENTS:
Refer urgently to hospital If sti neck or fever, give IM antibiotics and IM antimalarial If accid paralysis in adolescent less than 15 years, report urgently to EPI programme If recent convulsion, have diazepam available during referral Consider HIV-related illness (p. 54)
SINUSITIS
Give appropriate oral antibiotics Give ibuprofen If recurrent, consider HIV-related illness (p. 54) Give ibuprofen and observe response If more pain control is needed, see Palliative Care guidelines on acute pain
Repeated headaches with - Visual defects or - Vomiting or - One-sided or - Migraine diagnosis None of the above
MIGRAINE
TENSION HEADACHE
Give paracetamol Check visiontry glasses if... Suggest neck massage Reduce: stress, alcohol and drug use Refer if headache more than 2 weeks If on ARV drugs, this may be a side eect (see Chronic HIV Care)
Use this table if painful leg neuropathy

Painful burning or numb or cold feeling in feet or lower legs
PAINFUL LEG If on INH, give pyridoxine. If chronic diarrhoea, try ORS. NEUROPATHY
Consider HIV-related illness (p. 54), syphilis (do RPR, p.112); diabetes (check sugar); ARV side eectsee Chronic HIV Care. Refer for further assessment if cause unclear. Treat with low dose amitriptyline (p. 82). Follow up in 3 weeks.
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47
Use if cognitive problemsproblems thinking or remembering or disorientation SIGNS:

Recent onset of confusion or Diculty speaking or Loss of orientation or Restless and agitated or Reduced level of consciousness
CLASSIFY AS:
DELIRIUM
TREATMENTS:
Refer to hospital Give antimalarial pre-referral if malaria risk (p. 70) Give glucose and thiamine (check blood glucose) Treat physical cause (systemic illness) or alcohol or drug/ medication toxicity or withdrawal Consider HIV-related illness (p. 54). If HIV-related, may improve on ARV therapy If not able to refer, also give uids If very agitated and not alcohol or drug intoxicated, give low dose sedation with haloperidol (p. 85) Refer for assessment if cause uncertain. Every patient with dementia needs a full assessment once to exclude a reversible cause Consider HIV-related illness (p. 54) If HIV-related, may improve on ARV therapy Advise family In elderly, make sure adequately hydrated If known diagnosis, arrange for home care support to provide a safe, protective environment. Supportive contact with familiar people can reduce confusion Reassure patient and relatives
No reduced level of consciousness with: Serious memory problems or Misplaces important objects or Loss of orientation
DEMENTIA
Occasional decreased concentration or Minor short term memory loss
NORMAL AGING
48
NOTES:
49
If patient has a mental problem, looks depressed or
anxious, sad, fatigued or alcohol problem or recurrent multiple problems

IF YES, ASK: LOOK AND FEEL
Does patient appear: - Agitated? - Depressed? Is patient oriented to time and place? Is patient confused? Does the patient express bizarre thoughts? If yes, - Does the patient express incredible beliefs (delusions) or see or hear things others cannot (hallucinations)? - Is the patient intoxicated with alcohol or on drugs which might cause these problems? Does patient have a tremor? If fatigue or loss of energy, consider treatable causes of fatigue such as anaemia (p. 18), infection, medications, lack of exercise, sleep problems, fear of illness, HIV disease progression. If confusion or cognitive problems, see page 46. If bizarre thoughts If sad or loss of interest or decreased energy
How are you feeling? (Listen without interrupting). Ask: - Do you feel sad or depressed? - Have lost interest/pleasure in things you usually enjoy? - Do you have less energy than usual? If yes to any of the above three questions, ask for these depression symptoms: - Disturbed sleep. - Appetite loss (or increase). - Poor concentration. - Moves slowly. - Decreased libido. - Loss of self-condence or esteem. - Thoughts of suicide or death. - Guilty feelings. Have you had bad news for yourself or your family? If suicidal thoughts, assess the risk: - Do you have a plan? - Determine if patient has the means. - Find out if there is a xed time frame. - Is the family aware? - Has there been an attempt? How? Potentially lethal? Do you drink alcohol? If yes: - Calculate drinks per week over last 3 months. - Have you been drunk more than 2 times in past year?
If tense, anxious, or excess worrying, page 52 If more than 21 drinks/week for men, 14 for women or drunk more than twice in last year, page 52
50
Use this table if sad or loss of interest or decreased energy SIGNS:

Suicidal thoughts If patient also has a plan and the means, or attempts it with lethal means, consider high risk 5 or more depression symptoms and Duration more than 2 weeks
CLASSIFY AS:
SUICIDE RISK
TREATMENTS:
If high risk, refer for hospitalization (if available) or arrange to stay with family or friends (do not leave alone) Manage the suicidal person Remove any harmful objects Mobilize family support Follow up If suspect bipolar disorder (manic at other times), refer for lithium If patient is taking efavirenz (EFV), see Chronic HIV Care, p. H41. Otherwise, start amitryptiline (p. 82) Educate patient and family about medication Refer for counselling if available or provide basic counselling to counter depression Follow up Counsel to counter depression Give amitryptiline if serious problem with functioning If problems with sleep, suggest solutions Follow up in 1 week
MAJOR DEPRESSION
Less than 5 depression symptoms or More than 2 months of bereavement with functional impairment Bereaved but functioning
MINOR DEPRESSION/ COMPLICATED BEREAVEMENT
DIFFICULT LIFE EVENTS/LOSS
Counsel, assure psychosocial support If acute uncomplicated bereavement with high distress and not able to sleep, give _____________________
Use this table in all with bizarre thoughts

Delusions or Hallucinations
POSSIBLE PSYCHOSIS
Exclude alcohol intoxication or drug toxicity or ARV side eect (especially EFV) Consider infectionsee Delirium, p. 48 Refer for psychiatric care If acutely agitated or dangerous to self or others, give haloperidol (p. 83)
51
Use this if tense, anxious or excess worrying SIGNS:

Sudden episodes of extreme anxiety or Anxiety in specic situations or Exaggerated worry or Inability to relax
CLASSIFY AS:
ANXIETY DISORDER
TREATMENTS:
If severe anxiety, consider short-term use of antianxiety medication Counsel on managing anxiety according to specic situation Teach patients slow breathing and progressive relaxation Follow up in 2 weeks
Use this if more than 21 drinks/week for men, 14 for women or drunk more than twice in last year
Two or more of: Severe tremors or Anxiety or Hallucinations
SEVERE WITHDRAWAL SIGNS
Refer to a treatment center or hospital Give diazepam for withdrawal if not able to refer; monitor daily Give thiamine and glucose if poor nutrition Assess further using WHO AUDIT and counsel (use brief intervention guidelines for hazardous alcohol use)
Possible excessive alcohol use
HAZARDOUS ALCOHOL USE
Assess and treat other problems If:
Pain from chronic illness Constipation Hiccups Trouble sleeping see Palliative Care module.
If chronic illness, see chronic care modules.
52
Consider HIV-related Illness
53
Consider HIV-Related Illness
Clinical Signs of Possible HIV Infection

Repeated infections Herpes zoster Skin conditions including prurigo, seborrhoea Lymphadenopathy (PGL)painless swelling in neck and armpit Kaposi lesions (painless purple lumps on skin or palate) Severe bacterial infectionpneumonia or muscle infection Tuberculosispulmonary or extrapulmonary Oral thrush or oral hairy leukoplakia Oesophageal thrush Weight loss more than 10% without other explanation More than 1 month: - Diarrhoea (unexplained) - Vaginal candidiasis - Unexplained fever - Herpes simplex ulceration (genital or oral) Other indications suggesting possible infection: - Other sexually transmitted infections - A spouse or partner or child: -- known to be HIV positive -- has HIV or HIV-related illness - Unexplained death of young partner - Injecting drug use - High risk occupation
Co se nsid ex nd s er (p. ami put TB a th 106 nati ums nd es ) i on fo es fa o r ign ny f T s: of B
Cough for more than 2 weeks Father, mother, partner, or sibling diagnosed as TB Weight loss Hemoptysis Painless swelling in neck or armpit Sweats Weight loss
54
If HIV status is unknown, advise to be tested for HIV infection: Provide key information about HIV and AIDS, including how
HIV is transmitted (p. 96). This may be provided by health worker or lay provider performing HIV testing and counseling or in a group pre-testing counselling session. Discuss advantages of knowing HIV status. - Discuss how testing results will help in planning and management. Encourage patient to share her results with you. - Explain available treatments for HIV infection in the area: -- Acute and chronic clinical care. -- INH and cotrimoxazole prophylaxis. -- ARV therapy. Explain availability and when it is used (see Chronic HIV Care module). -- Explain what follow-up and ongoing support is available. Discuss advantages and disadvantages of disclosure and involvement of the partner. Oer HIV testing and counsellingsee page 96. Make sure testing is voluntary, after informed consent.
If patient has signs in bold in the gray box on the previous page:
These signs indicate HIV clinical stage 3 or 4. Patient is likely eligible for ARV therapy. HIV testing is urgent (see Chronic HIV Care with ARV Therapy module).
For patients with a positive HIV test:

Obtain a CD4 count if available. Provide ongoing HIV Careuse the Chronic HIV Care module.
55
56
Prevention: Check Status of Routine Screening, Prophylaxis and Treatment

Do this in all acute and chronic patients!
57
Prevention: Screening and Prophylaxis
ASSESS
Ask whether patient and family are sleeping under a bednet. - If yes, has it been dipped in insecticide? Is patient sexually active? (For adolescent: have you started having sex yet?) Determine if patient is at risk for HIV infection. Is patients HIV status known? Does patient smoke? If adolescent, do you feel pressure to do so? Does patient drink alcohol? If yes, calculate drinks/week over last 3 months. Have you had 5 or more drinks on 1 occasion in last year?
TREAT AND ADVISE

Encourage use of insecticide-treated bednet.
Counsel on safer sex. See next page for adolescents. Oer family planning. If unknown status: - Oer HIV testing and explain its advantages (p. 98). - Counsel after HIV testing. If yes, counsel to stop smoking (see Brief Interventions: Smoking Cessation). If adolescent: Educate on hazards, help to say no. If more than 21 drinks/week for men, 14 for women or 5 drinks at once, assess further and counsel to reduce or quit (see Hazardous Alcohol module). If adolescent: Educate on hazards, help to say no.
Has patient over 15 years been Measure blood pressure. Repeat screened for hypertension within last measurement if systolic > 120 mmHg . 2 years? If still elevated, see hypertension guidelines. Occupation with back strain or history of back pain. Exercises to stretch and strengthen abdomen and back. Correct lifting and other preventive interventions.
58
ASSESS
In adolescent girls and women of childbearing age: Check Tetanus Toxoid (TT) immunization status: - When was TT last given? - Which doses of TT was this?
TREAT AND ADVISE

If Tetanus Toxoid (TT) is due: Give 0.5 ml IM, upper arm. Advise her when next dose is due. Record on her card. TETANUS TOXOID (TT or Td) SCHEDULE: At rst contact with woman of childbearing age or at rst antenatal care visit, as early as possible during pregnancy. At least 4 weeks after TT1 >TT2. At least 6 months after TT2 >TT3. At least 1 year after TT3 >TT4. At least 1 year after TT4 >TT5. If pregnant, discuss her plans, follow antenatal care guidelines. If not pregnant, oer family planning.
In women of childbearing age: - Is she pregnant?
SPECIAL PREVENTION FOR ADOLESCENTS Counsel to:
See Adolescent Job Aid.
Delay sexual activity. Counsel to start sexual activity only when ready to deal with challenges that accompany sexinfection with HIV and other sexually transmitted infections and unwanted pregnancy. Young people may know very little about HIV and how it is transmitted. Be sure to check their understanding expecially about how to protect themselves. Advise to explore sexual pleasure in other safe forms of intimacy (thigh sex, masturbation, massage, touching, hugging). No contact with the partners semen or vaginal secretion and no unprotected vaginal or anal sex. Find non-sexual activities that you and your partner enjoy. Advise to reduce the number of sexual partners or, better yet, be faithful to one. Advise to protect themselves by using both condoms and another method of contraception (dual protection). Demonstrate how to use a condom. Discuss appropriate ways of saying no to unwanted sex and negotiating condom use. Reinforce skills to say no (teach or refer if she does not have the skills). Make sure girls understand that HIV risk increases with age of the man. If unprotected sexual intercourse, advise on emergency contraception and prevention and treatment of STI within 72 hours. If rape, see Quick Check. Advise on voluntary counselling and testing for HIV. Are you using drugs? Do you feel pressure to do so? Educate on hazards, help to say no.
59
Preventing HIV by Using Condoms
1.
Open the untorn condom
4.
Hold condom and remove penis from vagina while still erect
2.
Squeeze air from the teet of the condom
5. 3.
Roll rim of condom on erect penis
Knot condom to avoid spilling sperm. Throw used condom in pit latrine or burn them
60
61
Follow-up pneumonia
After 2 days, assess the patient: Check the patient with pneumonia using the Look and Listen part of the assessment on page 16. Also ask, and use the patients record, to determine: - Is the breathing slower? - Is there less fever? - Is the pleuritic chest pain less? - How long has the patient been coughing? Treatment: If signs of SEVERE PNEUMONIA OR VERY SEVERE DISEASE or no improvement in pleuritic chest pain, give IM antibiotics and refer urgently to hospital. If breathing rate and fever are the same, change to the second-line oral antibiotic and advise to return in 2 days. Exception: refer to hospital if the patient: - has a chronic disease or - is over 60 years of age or - has suspected or known HIV infection If breathing slower or less fever, complete the 5 days of antibiotic. Return only if symptoms persist. Also: If still coughing and cough present for more than 2 weeks, send 3 sputums for TB or send the patient to district hospital for sputum testing. Consider HIV-related illness (p. 54). If recurrent episodes of cough or dicult breathing and a chronic lung problem has not been diagnosed, refer patient to district hospital for assessment.
62
Follow-up TB: diagnosis based on sputum smear microscopy (three sputum samples)
If:
Two (or three) samples are positive
Then:
Patient is sputum smear-positive (has infectious pulmonary TB). Patients need TB treatmentsee TB Care. Diagnosis is uncertain. Refer patient to clinician for further assessment. Patient is sputum smear-negative for infectious pulmonary TB: - If no longer coughing, no treatment is needed. - If still coughing, refer to a clinician if available, or treat with a nonspecic antibiotic such as cotrimoxazole or ampicillin. If cough persists, repeat examination of three sputum smears.
Only one sample is positive All samples are negative
63
Follow-up fever
If high or low malaria riskexamine malaria smear If persistent feverconsider: TB HIV-related illness (see p. 54) Refer if unexplained fever 7 days or more
Follow-up persistent diarrhoea in HIV negative patient (for HIV positive, see Chronic HIV Care module)
Advise to drink increased uids (see Plan A, p. 88). Continue eating. Consider giardia infectiongive metronidazole and follow up in 1 week. Stop milk products (milk, cheese). If elderly or conned to bed, do rectal exam to exclude impaction (diarrhoea can occur around impaction). If blood in stool, follow guidelines for dysentery. If fever, refer. If no response, refer. District clinician should evaluate.
Follow-up oral or oesophageal candida

For suspected oesophagitisif no response and not able to refer, give aciclovir if mouth lesions suggest herpes simplex. If not already tested for HIV, encourage testing and counselling. If HIV positive, see Chronic HIV Care module.
64
Follow-up anogenital ulcer

If ulcer is healed: no further treatment If ulcer is improving: Continue treatment for 7 more days Follow up in 7 days If no improvement: refer
Follow-up urethritis (male)

Rapid improvement usually seen in a few days with no symptoms after 7 days. If not resolved, consider the following: Has patient been reinfected? Were partners treated? If not, treat partners and patient again. Make sure treatment for both GC and chlamydia was given and that patient adhered to treatment. If not, treat again. If trichomonas is an important cause of urethritis locally, treat patient and partner with metronidazole. If patient was adherent and no reinfection likely and resistant GC is common, give second-line treatment or refer.
For all patients Promote and provide condoms. Oer HIV testing and counselling, p. 98. Educate on STI, HIV and risk reduction.
Follow-up candida vaginitis

Some improvement usually seen in a few days with no symptoms after 7 days of treatment. If symptoms persist: Re-treat patient. Ask about oral contraceptive or antibiotic usethese can contribute to repeated candida infections. Consider HIV infection or diabetes, particularly if symptoms of polyuria or increased thirst or weight loss. Check urine glucoseif present, refer for fasting blood sugar, repeat candida infections are common. Consider prophylaxis (H16). Consider treating for cervicitis if not treated on the rst visit.
65
Follow-up bladder infection or menstrual problem

Consider STI if symptoms persisttreat patient and partner for GC/chlamydia. If polyuria continues or is associated with increased thirst or weight loss, check for diabetes mellitus by dipstick of urine. If positive for sugar, refer for fasting blood sugar and further assessment. Check adherence to treatment.
Follow-up PID
Some improvement usually seen in 1-2 days but it may take weeks to feel better (chronic PID can cause pain for years). If no improvement: Consider referral for hospitalization. If IUD in place, consider removal. If some improvement but symptoms persist: Extend treatment. Make sure partner has been treated for GC/chlamydia. Follow up regularly and consider referral if still not resolved.
For all patients Promote and provide condoms. Oer HIV testing and counselling, p. 98. Educate on STI, HIV and risk reduction.
Follow-up BV or trichomonas vaginitis

Some improvement usually seen in a few days with no symptoms after 7 days. If symptoms persist: Re-treat patient and partner at same time. Consider treating candida infection and cervicitis if these were not treated on the rst visit. For bacterial vaginosis (BV), make sure she avoids douching or using agents to dry vagina. Consider possibility of cervical cancer.
66
Treatments
Special advice for prescribing medications for symptomatic HIV or elderly patients
For some medications, start low, go slow. (Give full dose of antimicrobials and ARV drugs). Expect the unexpectedunusual side eects and drug interactions. Need for dynamic monitoringyou may need to adjust medications with change in weight and illness. If on ARV therapy, be sure to check for drug interactions before starting any new medicationsee Chronic HIV Care module.
67
Treatment
Instructions for Giving IM/IV Drugs:

Explain to the patient why the drug is given. Determine the dose appropriate for the patients weight. For some drugs, it is preferable to calculate exact dose for weight. Use a sterile needle and sterile syringe for each patient. Measure the dose accurately.
68
Give benzathine penicillin

For syphilis: Do not treat again for positive RPR if patient and partner both treated within last 6 months. Treat woman and her partner with 2.4 million units benzathine penicillin. If pregnant, plan to treat newborn. If allergic to penicillin: give doxycycline 100 mg twice daily for 14 days or tetracycline 500 mg orally 4 times daily for 14 days. For rheumatic fever/heart disease (RF/RHD) prophylaxis: Give 1.2 million units every 4 weekssee RF/RHD Chronic Care module. Adolescent or adult BENZATHINE PENICILLIN IM Add 5 ml sterile water to vial containing 1.2 million units = 1.2 million units/6 ml total volume
Primary syphilis Prophylaxis: RF/RHD Suspect streptococcal pharyngitis 12 ml (6 ml in each buttock) 6 ml every 4 weeks 6 ml once
Give glucose
Give by IV. Make sure IV is running well. Give by slow IV push. 50% GLUCOSE SOLUTION* Adolescent or Adult
*
25% GLUCOSE SOLUTION 50 - 100 ml
10% GLUCOSE SOLUTION (5 ml/kg) 125 - 250 ml
25 - 50 ml
50% glucose solution is the same as 50% dextrose solution or D50. This solution is irritating to veins. Dilute it with sterile water or saline to produce 25% glucose solution.
If no IV glucose is available, give sugar water by mouth or nasogastric tube. To make sugar water, dissolve 4 level teaspoons of sugar (20 grams) in a 200 ml cup of clean water.
69
Give IM antimalarial
Give initial IM loading dose before referral. Quinine 20 mg/kg: If IM, give same dose divided equally into twoone in each anterior thigh. If IV, dilute the loading dose with 10 ml/kg of IV uid and infuse slowly over 4 hours. Or artemether: Give one IM injection. When able to take oral treatment, give a single dose of sulfadoxinepyrimethamine, or if on quinine, give an adult a 500 mg tablet three times daily (children 10 mg/kg) to complete 7 days of treatment.
always give glucose with quinine
QUININE* IM 20 mg/kg (Loading Dose)

150 mg/ml* (in 2 ml ampoules)
4 ml 5.4 ml 7 ml 8 ml
ARTEMETHER (Loading Dose)

1 ml 2 ml 2 ml 2 ml
WEIGHT
30-39 kg 40-49 kg 50-59 kg 60-69 kg

2 ml 2.6 ml 3.4 ml 4 ml
If not able to refer, continue treatment as follows: After loading dose of artemether, give 1 ml artemether IM each day for 3 days until able to take oral medication. After loading dose of quinine, give quinine 10 mg/kg (half of above dose) every 8 hours in adults (every 12 hours in children) until able to take oral. If giving quinine by IV, dilute with 10 ml/kg or IV uid and infuse slowly over 4 hours. If IM, give same dose divided equally in twoone in each anterior thigh.
* Dosages are appropriate for quinine dihydrochloride. If quinine base, give 8.2 mg/kg every 8 hours.
70
Give diazepam IV or rectally

Call for help to turn and hold patient. Draw up 4 ml dose from an ampoule of diazepam into a 5 ml syringe. Then remove the needle. Insert small syringe 4 to 5 centimeters into the rectum and inject the diazepam solution.
DIAZEPAM RECTALLY 10 mg/2 ml solution 0.5 mg/kg
Initial dose Second dose 4 ml (20 mg) 2 ml (10 mg)
IV 0.2-0.3 mg/kg
2 ml (10 mg) 1 ml (5 mg)
Hold buttocks together for a few minutes.
If convulsion continues after 10 minutes, give a second, smaller dose of 1 ml diazepam IV or 2 ml rectally. Maintenance dose during transportation if needed and health worker accompanies: 2 ml rectal dose can be repeated every hour during emergency transport or Give slow IV infusion of 10 mg diazepam in 150 ml over 6 hours. Stop the maintenance dose if breathing less than 16 breaths per minute. If respiratory arrest, ventilate with bag and mask. Maximum total dose diazepam: 50 mg.
71
Give appropriate IV/IM antibiotic pre-referral

Classication Severe Pneumonia, Very Severe Disease Antibiotic First-line antibiotic: ______________________ (Common choice: benzylpenicillin plus gentamicin) Second-line antibiotic: ______________________ (Common choice: chloramphenicol) Very Severe Febrile Disease or suspect sepsis First-line antibiotic: ______________________ (Common choice: chloramphenicol) Second-line antibiotic: ______________________ (Common choice: benzylpenicillin plus gentamicin; or ceftriaxone) Severe soft tissue, muscle, or bone infection or suspected Staphylococcal infection First-line antibiotic: ______________________ (Common choice: cloxacillin) Second-line antibiotic: ______________________ (Common choice:
Severe or surgical abdomen or kidney infection
First-line antibiotic: ______________________ (Common choice: ampicillin plus gentamicin plus metronidazole) Second-line antibiotic: ______________________ (Common choice: ciprooxacin plus metronidazole)
72
IV/IM antibiotic dosing

WEIGHT BENZYLPENICILLIN Dose: 50 000 units per kg. GENTAMICIN Dose: 5 mg/kg/day. Calculate EXACT dose based on body weight. Only use these doses if this is not possible. Vial containing 20 mg = 2 ml at 10 mg/ml undiluted 15-19 ml 20-24 ml 25-29 ml 30-34 ml Vial containing 80 mg = 2 ml at 40 mg/ml undiluted 4-5 ml 5-6 ml 6-7 ml 7.5-8.6 ml
To a vial of 600 mg (1 000 000 units): Add 2.1 ml sterile water = 2.5 ml at 400 000 units/ml 30-39 kg 40-49 kg 50-59 kg 60-69 kg 4 ml 6 ml 7 ml 8 ml If not able to refer: Give above dose IV/IM every 6 hours
If not able to refer: Give above dose once daily
CHLORAMPHENICOL Dose: 40 mg per kg WEIGHT Add 5.0 ml sterile water to vial containing 1000 mg = 5.6 ml at 180 mg/ml
CLOXACILLIN Dose: 25-50mg/kg IV: To a vial of 500 mg add 8 ml of sterile water to give 500 mg/10 mls IM: Add 1.3 ml of sterile water to a vial of 250 mg to give 250 mg/1.5 ml 6-12 ml IM (20-40 ml IV) 7.5-15 ml (25-50 ml IV) 9-18 ml IM (30-60 ml IV) 10-20 ml IM (35-70 IV) If not able to refer: Give above dose IV/IM every 4-6 hours
AMPICILLIN Dose: 50mg/kg To a vial of 500 mg add 2.1 ml sterile water = 2.5 ml for 500 mg 10ml 12 ml 15 ml 18ml If not able to refer: Give above dose IV/IM every 6 hours
30-39 kg 40-49 kg 50-59 kg 60-69 kg
8 ml 10 ml 12 ml 14 ml If not able to refer: Give above dose IV/ IM every 12 hours
73
Give salbutamol by metered-dose inhaler

100 mcg/pu ; 200 doses/inhaler Use spacer and/or mask depending on patient.
If SEVERE WHEEZING with severe respiratory distress: give 20 pus of salbutamol in a row. If possible, give continuously by nebulizer.
If no response in 10 minutes, give epinephrine. *

If MODERATE WHEEZING or SEVERE WHEEZING without severe respiratory distress:
2 pus every 10 minutes x 5 times, then 2 pus every 20 minutes x 3 times, then 2 pus every 30 minutes x 6 times, then 2 pus every 3, 4 or 6 hours
If MILD WHEEZING: 2 pus every 20 minutes x 3 times, then 2 pus every 3 to 6 hours.
* For further management of wheezing, see Quick Check and Emergency Treatments or Asthma Guidelines.
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Instructions for Giving Oral Drugs

TEACH THE PATIENT HOW TO TAKE ORAL DRUGS AT HOME
Determine the appropriate drugs and dosage for the patients age and weight. Tell the patient the reason for taking the drug. Demonstrate how to measure a dose. Watch the patient practice measuring a dose by himself. Ask the patient to take the rst dose. Explain carefully how to take the drug, then label and package the drug. If more than one drug will be given, collect, count and package each drug separately. Explain that all the oral drug tablets must be used to nish the course of treatment, even if the patient gets better. Support adherence. Check the patients understanding before he or she leaves the clinic.
75
Give appropriate oral antibiotic

For pneumonia if age 5 years up to 60 years First-line antibiotic: ______________________ (Common choice: penicillin VK (oral) or cotrimoxazole) Second-line antibiotic: ______________________ (Common choice: amoxicillin or erythromycin) For pneumonia if age greater than 60 years First-line antibiotic: ______________________ (Common choice: amoxicillin or cotrimoxazole) Second-line antibiotic: ______________________ (Common choice: amoxicillin-clavulanate) For dysentery First-line antibiotic: ______________________ (Common choice: nalidixic acid or ciprooxacin) Second-line antibiotic: ______________________ (Common choice: ) For cholera First-line antibiotic: ______________________ Second-line antibiotic: ______________________ For abscess, soft tissue infection, folliculitis First-line antibiotic: ______________________ (Common choice: cloxacillin) Second-line antibiotic: ______________________ (Common choice: ) For chancroid (treat for 7 days) First-line antibiotic:______________________ (Common choice ciprooxacin or erythromycin) Second-line antibiotic: ______________________ For lymphogranuloma venereum, treat for 14 days First-line antibiotic: ______________________ (Common choice: doxycycline) Second-line antibiotic: ______________________ For reactive lymphadenopathy First-line antibiotic: ______________________ Second-line antibiotic: ______________________ For outpatient treatment PID ciprooxacin 500 mg single dose plus doxycycline twice daily for 14 days plus metronidazole 500 mg twice daily for 14 days
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COTRIMOXAZOLE (trimethoprim + sulphamethoxazole) Give two times daily for 5 days AGE or WEIGHT ADULT TABLET 80 mg trimethoprim + 400 mg sulphamethoxazole 1
AMOXICILLIN Give three times daily for 5 days
CLOXACILLIN Give three times daily for 5 days TABLET 500 mg
TABLET 500 mg
TABLET 250 mg
5 years to 13 years (19-50 kg) 14 years or more (> 50 kg)
1/2
DOXYCYCLINE * Give two times daily for 5 days (avoid doxycycline in young adolescents) AGE or WEIGHT 5 years to 13 years (19-50 kg) 14 years or more (> 50 kg) TABLET 100 mg
ERYTHROMYCIN Give 4 times daily for 5 days
PEN VK Give 3 times daily for 5 days
CIPROFLOXACIN Give 2 times daily for 7 to 14 days
TABLET 500 mg
TABLET 250 mg
TABLET 500 mg
TABLET 500 mg
1/2
I/2
* Avoid Doxycycline in yound adolescents.
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Give antibiotics for possible GC/Chlamydia infection

IN NON-PREGNANT WOMAN, OR MAN: First-line antibiotic combination for GC/chlamydia: _________________ ________________________ (Common choice: ciprooxacin plus doxycycline) Second-line antibiotic combination if high prevalence resistant GC or recent treatment: ________________________________
IN PREGNANT WOMAN: First-line antibiotic combination for GC/chlamydia:_________________ _______________________ (Common choice: cexime plus amoxycillin) Second-line antibiotic combination if high prevalence resistant GC or recent treatment: _______________________________
Antibiotics for gonorrhoea (GC)

SAFE FOR USE IN PREGNANCY:
Ceftriaxone Cexime 400 mg Spectinomycin Kanamycin NOT SAFE FOR USE IN PREGNANCY: Ciprooxacin 250 mg 500 mg 1 tablet in clinic 2 grams IM 2 grams IM 2 tablets in clinic 1 tablet in clinic 125 mg IM
78
Give metronidazole
Advise to avoid alcohol when taking metronidazole For bacterial vaginosis or trichomoniasis
METRONIZADOLE
250 mg tablet Adolescent or adult 2 grams (8 tablets) at once in clinic or 2 tablets twice daily for 7 days
For persistent diarrhoea, bloody diarrhoea, PID or severe gum/mouth infection:

Weight
METRONIZADOLE 250 mg tablet twice daily

for seven days
METRONIZADOLE 500 mg tablet twice

daily for 7 days
Adolescent or adult
Antibiotics for chlamydia

SAFE FOR USE IN PREGNANCY:
Amoxycillin 500 mg 250 mg Azithromycin 250 mg Erythromycin base 250 mg base 500 mg 1 tablet 3 times daily for 7 days 2 tablets 3 times daily for 7 days 4 capsules in clinic 2 tablets 4 times daily for 7 days 1 tablet 4 times daily for 7 days
NOT SAFE FOR USE IN PREGNANCY OR DURING LACTATION:

Doxycyline 100 mg Tetracycline 500 mg 1 tablet 2 times daily for 10 days 1 tablet daily for 10 days
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Give appropriate oral antimalarial

First-line antimalarial: ______________________ Second-line antimalarial: ____________________
* Do not use sulfdadooxine/pyrimethamine for treatment if patient is on cotrimoxazole prophylaxis.
CHLOROQUINE Give for 3 days AGE or WEIGHT SULFADOXINE/ PYRIMETHAMINE Give single dose in clinic TABLET (500 mg sulfadoxine + 25 mg pyrimethamin)
1 1/2
ARTESUNATE + AMODIAQUINE Daily for 3 days TABLET (50 mg rtesunate + TABLET 150 mg base amodiaquine)
2+2
ARTEMETHER/ LUMEFANTRINE Twice daily for 3 days TABLET (20 mg artemether + 120 mg lumefantrine)
2
TABLET (150 mg base)

Day 1 Day 2 Day 3
TABLET (100 mg base)

Day 1 Day 2 Day 3
5 yr-7 yr (19-24 kg) 8 yr-10 yr (25-35 kg) 11 yr-13 yr or small or wasted adult (3650 kg) 14 yr + (> 50 kg)
1 1/2 2 1/2 3
1 1/2 2 1/2 3
2 1/2 3 1/2 5
2 1/2 3 1/2 5
2+2
2 1/2
2 1/2
3+3
4+4
Give paracetamol for pain

Give every 6 hours (or every 4 hours if severe pain). Do not exceed 8 tablets (4 grams) in 24 hours. If pain not
controlled with paracetamol, alternate aspirin with paracetamol. If pain is chronic, see Palliative Care guidelines P8. If severe acute pain, see Quick Check module.
Adolescent or Adult
40-50 kg or more 50 kg or more
paracetamol 500 mg tablet

1 tablet 1-2 tablets
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Give albendazole or mebendazole

albendazole 400 mg single dose OR mebendazole 500 mg single dose
Give prednisolone
For acute moderate or severe wheezing, before referral:
Give prednisolone or prednisone 60 mg orally. Or if not able to take oral medication give either: - hydrocortisone 300 mg IV or IM, or - methyprednisolone 60 mg IV/IM
For asthma or COPD not in control, where prednisone is in the
treatment plan, give prednisolone or prednisone. Give high dose for several days then taper, stop. COPD may require longer treatment at low level (see Practical Approach to Lung HealthPAL Guidelines).
prednisone or prednisolone 5 mg tablets

Day 1 Day 2 7 Day 3 7 Day 4 6 Day 5 5 Day 6 4 Day 7 3
ADULT
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Give amitriptyline
Useful for depression; insomnia; helps relieve pain when used with opioids; for some neuropathic pain; in low dose for sleep.
For depression:
Educate about the drug (patient and family): Not addictive. Do not use with alcohol. Takes 3 weeks to get a response in depressiondont be discouraged; often see eect on sleep or pain within 2-3 days. May feel worse initially. Side eects usually fade in 7-10 days (dry mouth, constipation, diculty urinating, dizziness). Will need to continue for 6 months. Do not stop abruptly. If suicide risk, give only 1 week supply at time or have caregiver dispense drug. May impair ability to perform skilled tasks such as drivingtake precautions until used to drug.
For painful foot/leg neuropathy:
Low dose amitripyline25 mg at night or 12.5 mg twice daily (some experts advise starting as low as 12.5 mg daily. Wait 2 weeks for response, then increase gradually to 50 mg
For problems with sleep:
Use low dose at night12.5 to 25 mg.

Weight Starting dose After 2 weeks, increase to: 2 weeks later if inadequate response
50 mg AM 100 mg at night
< 40 kg 40 kg or more
0.5-1 mg/kg 50 mg at night 25 mg AM 75 mg at night
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Give haloperidol
If psychosis with acute agitation or dangerous to self or others:
For the most uncontrollable patients Give haloperidol 5 mg IM every hour up to 3 injections (total 15 mg). For less disturbed patients Give 1-2 mg haloperidol orally 2-5 times per day. If necessary, give 2 mg IM every 4-6 hours up to total dose 15 mg . For delirium in elderly or HIV infection or other complicating illness Give low dose haloperidol 0.51.0 mg orally once or twice daily. Avoid sedatives (diazepam). Side eects are more common. For vomiting: Give 0.5 to 1 mg orally once or twice daily.
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Treat with nystatin

Treat oral thrush with nystatin:
Suck on nystatin uncoated lozenges twice daily or apply nystatin suspension 5 times daily (after each meal and between meals) for 7 days (or until 48 hours after lesions resolve).
Treat candida vaginitis with nystatin pessaries:
Dosage: 100 000 IU daily by vaginal pessaries. Dispense 14 nystatin suppositories. If relapsetreat rst week of every month or when needed (consider HIV-related illness and diabetes).
Treat with antiseptic

Wash hands before and after each treatment.
To treat impetigo or herpes zoster with local bacterial infection: Gently wash with soap and water. Paint with topical antiseptic. Choices include: - chlorhexidine - polyvidone iodine - full-strength gentian violet (0.5%) - brilliant green Keep skin clean by washing frequently and drying after washing.
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Give aciclovir
Primary infection:
200 mg 5 times daily for 7 days or 400 mg 3 times daily for 7 days.
Recurrent infection:
As above except for 5 days only.
Give uconazole
For resistant oral thrush or vaginal candidiasis:
oral 200 mg in clinic then 100 mg daily for 7-14 days until resolved. For suspected oesophageal candidiasis: oral 400 mg in clinic then 200 mg per day for 14 days. If no response in 3-5 days, increase to 400 mg per day. Avoid in pregnancy.
Apply podophyllin
By health worker10-20% in compound tincture of benzoin.
Apply weekly. Apply only to wartsavoid and protect normal tissue. Let dry. Wash thoroughly 1-4 hours after application.
By patientonly if Podolox or Imiquimod are available.
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Treat scabies
Treat with either: Treatment period Warnings For all treatmentswill initially itch more (as mites die and lead to inammatory response) and then itch goes away Potentially toxic if overused Avoid in pregnancy and small children
1% Lindane (gamma benzene hexachloride) cream or lotion 25% benzyl benzoate emulsiondilute 1:1 for children; 1:3 for infants 5% permethrin cream
Oncewash o after 24 hours (after 12 hours in children)
At night, wash o in Tendency to irritate the skin morningrepeat x 3? (variable recommendations) Expensive, very low systemic absorption and toxicity
Patient and all close contacts must be treated simultaneouslywhole
household and sexual partners, even if asymptomatic. Do not bathe before applying the treatment (increases systemic absorption and does not help). Apply the cream to the whole skin surface giving particular attention to the exures, genitalia, natal cleft, between the ngers and under the ngernails. Include the face, neck and scalp but avoid near the eyes and mouth. The cream may irritate the skin a little, especially if there are excoriations. Keep on for the treatment period. If any cream is washed o during the treatment period (e.g., hands) reapply immediately. Wash the cream o at the end of the treatment period. Itching should start to diminish within a few days but may persist for a number of weeks. This does not mean that the treatment has failed. Another cream may help with the itching (crotamiton or topical steroid).
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Advise on symptom control for cough/cold/bronchitis

Advise to use a safe, soothing remedy for cough
Safe remedies to recommend:
Harmful remedies to discourage:
If running nose interferes with work:
suggest decongestant
For fever, give paracetamol (p. 78)
Give iron/folate
For anaemia: 1 tablet twice daily
iron/folate tablets: iron 60 mg, folic acid 400 microgram
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Dehydration
Plan A for adolescents/adults: treat diarrhoea at home.
Counsel the patient on the 3 Rules of Home Treatment: Drink extra uid, continue eating, when to return. 1. Drink extra uid (as much as the patient will take)any uid (except uids with high sugar or alcohol) or ORS. Drink at least 200-300 ml in addition to usual uid intake after each loose stool. If vomiting, continue to take small sips. Antiemetics are usually not necessary. Continue drinking extra uid until the diarrhoea stops. - It is especially important to provide ORS for use at home when: -- the patient has been treated with Plan B or Plan C during this visit. -- the patient cannot return to a clinic if the diarrhoea gets worse. -- the patient has persistent diarrhoea or large volume stools.
IF ORS is provided: TEACH THE PATIENT HOW TO MIX AND DRINK ORS. GIVE 2 PACKETS OF ORS TO USE AT HOME.
2. Continue eating. 3. When to return.
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Plan B for adolescents/adults: treat some dehydration with ORS
Give in clinic recommended amount of ORS over 4-hour period. Determine amount of ORS to give during rst 4 hours.
* Use the patients age only when you do not know the weight. The approximate amount of ORS required (in ml) can also be calculated by multiplying the patients weight (in kg) times 75.
- If the patient wants more ORS than shown, give more.

AGE* WEIGHT In ml 5-14 years 20- < 30 kg 1000-2200 15 years and older 30 kg or more 2200-4000
If the patient is weak, help him or her take the ORS:

- Give frequent small sips from a cup. - If the patient vomits, wait 10 minutes. Then continue, but more slowly. - If patient wants more ORS than shown, give more.
After 4 hours:
- Reassess the patient and classify for dehydration. - Select the appropriate plan to continue treatment. - Begin feeding the patient in clinic.
If the patient must leave before completing treatment:

- Show how to prepare ORS solution at home. - Show how much ORS to give to nish 4-hour treatment at home. - Give enough ORS packets to complete rehydration. Also give 2 packets as recommended in Plan A. - Explain the 3 Rules of Home Treatment:
1. Drink extra uid 2. Continue eating 3. When to return
See Plan A for recommended uids
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Plan C: Treat severe dehydration quickly at any age
FOLLOW THE ARROWS. IF ANSWER IS YES, GO ACROSS. IF NO, GO DOWN.

START HERE
Can you give intravenous (IV) uid immediately?
YES
NO
Is IV treatment available nearby (within 30 minutes)?
YES
NO
Are you trained to use a naso-gastric (NG) tube for rehydration?
NO
Can the patient drink?
YES
NO
Refer URGENTLY to hospital for IV or NG treatment
90
Start IV uid immediately. If the patient can drink, give ORS by mouth while the drip is set up. Give 100 ml/kg Ringers Lactate Solution (or, if not available, normal saline), divided as follows: Age Infants (under 12 months) Older (12 months or older, including adults) First give: 30 ml/kg in: 1 hour* 30 minutes* Then give 70 ml/kg: 5 hours 2 1/2 hours
Repeat once if radial pulse is very weak or not detectable. Reassess the patient every 1-2 hours. If hydration status is not improving, give the IV drip more rapidly. Also give ORS (about 5 ml/kg/hour) as soon as the patient can drink: usually after 3-4 hours (infants) or 1-2 hours for children, adolescents, and adults. Reassess an infant after 6 hours and older patient after 3 hours. Classify dehydration. Then choose the appropriate plan (A, B, or C) to continue treatment.
Refer URGENTLY to hospital for IV treatment. If the patient can drink, provide the mother or family/friend with ORS solution and show how to give frequent sips during the trip.
Start rehydration by tube (or mouth) with ORS solution: give 20 ml/kg/hour for 6 hours (total of 120 ml/kg). Reassess the patient every 1-2 hours: - If there is repeated vomiting or increasing abdominal distension, give the uid more slowly. - If hydration status is not improving after 3 hours, send the patient for IV therapy. After 6 hours, reassess the patient. Classify dehydration. Then choose the appropriate plan (A, B, or C) to continue treatment.
NOTE: If possible, observe the child at least 6 hours after rehydration to be sure the mother can maintain hydration giving the child ORS solution by mouth.
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Refer urgently to hospital*

Discuss decision with patient and relatives. Quickly organize transport. Send with patient:
Health worker if airway problem or shock . Relatives who can donate blood. Referral note. Essential emergency supplies (below).
Warn the referral centre if possible by radio or phone. During transport:
Watch IV infusion. Keep record of all IV uids and medications given and time of administration. If transport takes more than 4 hours, insert Foley catheter to empty bladder; monitor urine output. *If referral is dicult and is refused: Adapt locally
* If chronic illness, determine if palliative care is preferred. Does patient have known terminal disease in a late stage? (HIV/ AIDS, COPD, lung cancer, etc). Discuss needs with family and patientcan these be better met at home, with support?
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Essential Emergency Supplies To Have During Transport

Emergency Drugs
Diazepam (parenteral) Artemether or Quinine Ampicillin Gentamicin IV glucose50% solution Ringers lactate (take extra if distant referral)
Quantity for Transport

30 mg 160 mg (2 ml) 300 mg 2 grams 240 mg 50 ml 4 litres
Emergency Supplies IV catheters and tubing

Clean dressings Gloves, one of which is sterile Clean towels Sterile syringes and needles Urinary catheter
Quantity for Transport

2 sets
at least 2 pairs 3
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94
Advise and Counsel
95
Advise and Counsel
Provide key information on HIV (Human Immune Deciency Virus)
Counsel on how HIV is transmitted and not transmitted. HIV is a virus that destroys parts of the bodys immune system. A person infected with HIV may not feel sick at rst, but slowly the bodys immune system is destroyed. He/she becomes ill and is unable to ght infection. Once a person is infected with HIV, he or she can give the virus to others. HIV can be transmitted through: Exchange of HIV-infected body uids such as semen, vaginal uid or blood during unprotected sexual intercourse. HIV-infected blood transfusions. Injecting drug use. Sharing of instruments for tattoo. From an infected mother to her child during: - pregnancy - labour and delivery - postpartum through breastfeeding HIV cannot be transmitted through hugging or kissing or mosquito bites. A special blood test is done to nd out if the person is infected with HIV.
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Discuss advantages of knowing HIV status
Knowing HIV status is important. If positive, knowing this will let the patient: Protect themselves from re-infection and their sexual partner(s) from infection. Gain early access to Chronic HIV Care and support including: - cotrimoxazole prophylaxis - regular follow-up and support - ARV therapy. Explain availability and when it is used (see Chronic HIV Care module). Cope better with HIV infection. Make choices about future pregnancies. Access interventions to prevent transmission from mothers to their infants (see PMTCT materials). Plan for the future. Explain the psychological and emotional consequences of HIV. If negative, knowing this will help the patient explore ways to remain negative. Encourage HIV testing and counselling Explain HIV testing (next page). Explain implications of results (p. 100). Counsel on safer sex, including correct and consistent use of condoms (p. 102). Provide condoms. If positive: It is especially important to practice safer sexto avoid infecting others, to avoid other sexually transmitted infections, and to avoid getting a second strain of HIV. Adult men should be advised to avoid sex with teenagers outside marriage, to avoid spreading the infection to the next generation. Discuss benets of disclosure and involving and testing the partner (p. 99). Use Chronic HIV Care module.
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HIV testing and counselling for clinical care
Explain about HIV testing and counselling: HIV testing and counselling enable people to learn whether they are infected. Testing is voluntary. The patient has the right to refuse. The HIV test will help with clinical care; knowing status has many advantages. It provides an opportunity to learn and accept HIV status in a condential environment. It includes a blood test with counselling before and after it. Test result will be kept condential within the medical team, for purposes of clinical care. It is patients decision about any further disclosure. Based on availability of testing in your facility and the patients preference:
98
If HIV testing and counselling are available in your facility and you are trained to do it, use national HIV guidelines to provide:
Pre-test counsellingessential components: - The advantages of knowing HIV status (p. 101). - Management of social and psychological consequence of a positive test and disclosure. - Availability of support and care after testing. Explain how test is performed. Obtain informed consent. Give results, discuss the implications of the test result (p. 98), and give post-test counselling. If HIV positive, begin providing HIV care (see Chronic HIV Care module). This includes ongoing counselling and support. Counsel on disclosure and benets of involving the partner (p. 101).
If HIV testing and counselling are not available in your facility, explain:
Where to go for in-clinic HIV testing and counselling. How test is performed. How test results will be made available and kept condential within the medical team. When and how results are given. Cost. Arrange to see patient after testing. Explain how the result will be used for clinical care, and the advantages of knowing HIV status. Give pre-test counselling.
If patient wants anonymous testing or condential testing from a separate HIV testing service, explain about VCT centres:
Address of VCT centre in your area
Discuss condentiality of the result from a VCT service:

Assure the patient that the test result is condential and may even be anonymous. The result will be only shared with him or her. The patient decides whom to disclose the result to. The result will only be provided to another person with his or her written consent.
If the result is needed for clinical care, explain the advantage of sharing the result with the medical team.
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Implications of the test result

Make sure patient wishes to receive the result (this is part of the informed consent process).
If test result is positive and has been conrmed: Explain her that a positive test result means that (s)he is carrying the infection. Give post-test counselling and provide support (p. H50). Oer ongoing care (see Chronic HIV Care module) and arrange a follow-up visit. If test result is negative: Share relief or other reactions with the patient. Counsel on the importance of staying negative by correct and consistent use of condoms and other practices to make sex safer. If recent exposure or high risk, explain that a negative result can mean either that he or she is not infected with HIV, or is infected with HIV, but has not yet made antibodies against the virus. (This is sometimes called the window period3 to 6 months.) Repeat HIV testing can be oered after 8 weeks. If the patient has not been tested, has been tested but does not want to know results, or does not disclose the result: Explain the procedures to keep the results condential. Reinforce the importance of testing and the benets of knowing the result. Explore barriers to testing, to knowing, and to disclosure (fears, misperceptions).
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Encourage disclosure
Ask the patient if they have disclosed their result or are willing to disclose the result to anyone. Discuss concerns about disclosure to partner, children, other family, friends. Assess readiness to disclose HIV status and to whom. Assess social support and needs (refer to support groups). See H59. Provide skills for disclosure (role play and rehearsal can help). Help the patient make a plan for disclosure. Encourage attendance of the partner to consider testing, explore barriers to this. Reassure that you will keep the result condential. If the patient does not want to disclose the result: Reassure that the results will remain condential. Explore the diculties and barriers to disclosure. Address fears and lack of skills (help provide skills). Continue to motivate. Address the possibility of harm to others. Oer another appointment and more help as needed (such as peer counsellors).
For women, discuss benets and possible disadvantages of disclosure of a positive result and involving and testing male partners.
Men are generally the decision makers in the family and communities. Involving them will: Have greater impact on increasing acceptance of condom use, practicing safer sex to avoid infection or avoiding unwanted pregnancy. Help to decrease the risk of suspicion and violence. Help to increase support to their partners. Motivate him to get tested. Disadvantages of involving and testing the partner: danger of blame, violence, abandonment. Health worker should try to counsel couples together, when possible.
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Counsel on safer sex and condom use
Safer sex is any sexual practice that reduces the risk of transmitting HIV and other sexually transmitted infections (STI) from one person to another. Protection can be obtained by: - Abstaining from sexual activity. - Correct and consistent use of condoms; condoms must be used before any penetrative sex, not just before ejaculation. - Choosing sexual activities that do not allow semen, uid from the vagina, or blood to enter the mouth, anus or vagina of the partner, and not touching the skin of the partner where there is an open cut or sore. If HIV positive: Explain to the patient that she/he is infected and can transmit infection to his/her partner. They should use a condom as above. If partners status is unknown, counsel on benets of involving and testing the partner (p. 101). For women: explain the extra importance of avoiding infection during pregnancy and breastfeeding. The risk of infecting the baby is higher if the mother is newly infected. If HIV negative OR result is unknown: Explain the risk of HIV infection and how to avoid it. If partners status is unknown, counsel on benets of testing the partner. For women: explain the extra importance of remaining negative during pregnancy and breastfeeding. The risk of infecting the baby is higher if the mother is newly infected during this time.
Make sure the patient knows how to use condoms and where to get them. Provide easy access to condoms in clinic in a discrete manner.
102
Educate and counsel on STI

Speak in private, with enough time and assure condentiality. Explain: Special counselling for adolescents: The disease. See Adolescent Job Aid How it is acquired. How it can be prevented. The treatment. Most STIs can be cured, exceptions are HIV and herpes. The need to also treat the partners (except for vaginitis): - Recent sex partner(s) are likely to be infected but may be unaware. - If partners are untreated, they may develop complications. - Sex with untreated partners can lead to re-infection. - Treatment of the partner, even if no symptoms, is important to the health of the partner and to you. Listen to the patient: what is the stress or anxiety, what aspect of STI? Promote safer sexual behaviour to prevent HIV and STI. Counsel on limiting partners (or abstinence) and careful selection of partners. Refer for counselling on: Instruct in condom use (p. 102). Educate on HIV. Advise HIV testing and counselling (p. 98).
Concerns about herpes infection (no cure) Possible infertility related to PID Behavioural risk assessment Patient with multiple partners Dicult circumstances or risk
Inform the partner(s) or spouse. Ask the patient, can you do this? Ask, is it possible for you to: - Talk with your partner about the infection? - Convince your partner to get treatment? - Bring/send your partner to the health centre? Determine your role as the health worker. Strategies to discuss and introduce condom use. Risk of violence or stigmatizing reactions from partners, family.
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104
Laboratory Tests
105
Collect sputum for examination for TB
Explain that the TB suspect needs a sputum examination to determine whether there are TB bacilli in the lungs. List the TB suspects name and address in the Register of TB Suspects. Label sputum containers (not the lids). 3 samples are needed for diagnosis of TB. 2 samples are needed for followup examination.
TB SPECIMEN Name: ______________________ Health facility: ________________ Date: _______________________ Specimen no. ________________
Fill out Request for Sputum Examination form. Explain and demonstrate, fully and slowly, the steps to collect sputum. Show the TB suspect how to open and close the container. Breathe deeply and demonstrate a deep cough. The TB suspect must produce sputum, not only saliva. Explain that the TB suspect should cough deeply to produce sputum and spit it carefully into the container.
Collect Give the TB suspect the container and lid. Send the TB suspect outside to collect the sample in the open air if possible, or to a well-ventilated place, with sucient privacy. When the TB suspect returns with the sputum sample, look at it. Is there a sucient quantity of sputum (not just saliva)? If not, ask the TB suspect to add some more. Explain when the TB suspect should collect the next sample, if needed.
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Schedule for collecting three sputum samples

Day 1:

Collect on-the-spot sample as instructed above (Sample 1). Instruct the TB suspect how to collect an early morning sample tomorrow (rst sputum after waking). Give the TB suspect a labelled container to take home. Ask the TB suspect to bring the sample to the health facility tomorrow.
Day 2:

Receive early morning sample from the TB suspect (Sample 2). Collect another on-the-spot sample (Sample 3).
When you collect the third sample, tell the TB suspect when to return for the results. Store Check that the lid is tight. Isolate each sputum container in its own plastic bag, if possible, or wrap in newspaper. Store in a cool place. Wash your hands.
Send Send the samples from health facility to the laboratory. (See page 109)
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108
REGISTER OF TB SUSPECTS
Age Complete Address M 1 2 3 F
Date Sputum Sent to Lab Date Results Received TB Treatment Card Opened? (record date)
Year _______________ Facility
______________________
Date
TB Suspect Number
Name of TB Suspect
Results of Sputum Examinations
Observations/ Clinicians Diagnosis
If negative, record Neg. If positive, record the grade (+, ++, +++). When a result is scanty, record the number.
TB LABORATORY FORM REQUEST FOR SPUTUM EXAMINATION

Name of health facility __________________________ Name of patient ______________________________ Date _________________ Age ______ Sex: M p F p
Complete address __________________________________________________________ _______________________________ Reason for examination: Diagnosis p OR Follow-up p Disease site: TB Suspect No. ______________ Patients District TB No.* _____________ Extrapulmonary p (specify)_______________ District _______________
Pulmonary p
Number of sputum samples sent with this form _____ Date of collection of first sample ____________ Signature of specimen collector ________
* Be sure to enter the patients District TB No. for follow-up of patients on TB treatment.
RESULTS (to be completed by Laboratory)

Lab. Serial No. ____________________________ (a) Visual appearance of sputum: Mucopurulent (b) Microscopy: DATE SPECIMEN 1 2 3 RESULTS +++ POSITIVE (GRADING) ++ + scanty (19) Blood-stained Saliva
Date _______
Examined by (Signature) __________________________________
The completed form (with results) should be sent to the health facility and to the District Tuberculosis Unit.
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Send sputum samples to laboratory

Keep the samples in a refrigerator or in as cool a place as possible until transport. When you have all three samples, pack the sputum containers in a transport box. Enclose the Request for Sputum Examination. (See previous page.) If there are samples for more than one patient, enclose a Request for Sputum Examination for each patients samples. If a patient does not return to the health facility with the second sample within 48 hours, send the rst sample to the laboratory anyway. Send the samples to the laboratory as soon as possible. Do not hold for longer than 34 days. The total time from collection until reaching the laboratory should be no more than 5 days. Sputum samples should be examined by microscopy no later than 1 week after they have been collected. Prepare a dispatch list to accompany each transport box. (See example below.) The dispatch list should identify the sputum samples in the box. Before sending the box to the laboratory: Check that the dispatch list states: the correct total number of sputum containers in the box, the identication numbers on the containers, the name of each patient. Check that a Request for Sputum Examination is enclosed for each patient. Close the box carefully. Write the date on the dispatch list. Put the dispatch list in an envelope and attach envelope to the outside of the transport box.
110
Insert instructions for lab tests which can be performed in clinic:

Haemoglobin Urine dipstick for sugar or protein Blood sugar by dipstick Malaria dipstick or smear Rapid test for HIV (with informed consent and counselling)
111
Perform RPR* test for syphilis and respond to results

Have patient sit comfortably on chair. Explain procedure and obtain consent. Put on gloves. Use a sterile needle and syringe. Draw up 5 ml blood from a vein. Put in a plain test tube. Let test tube sit 20 minutes to allow serum to separate. (Or centrifuge 3-5 minutes at 2000-3000 rpm.) In the separated sample, serum will be on top. Use sampling pipette to withdraw some of the serum. Take care not to include any red blood cells from the lower part of the separated sample. Hold the pipette vertically over a test card circle. Squeeze teat to allow one drop (50 micro-liter) of serum to fall onto a circle. Spread the drop to ll the circle using a toothpick or other clean spreader. Important: Several samples may be done on one test card. Be careful not to contaminate the remaining test circles. Use a clean spreader for every sample. Carefully label each sample with a patient name or number. Attach dispensing needle to a syringe. Shake antigen.* Draw up enough antigen for the number of tests done (one drop per test). Holding the syringe vertically, allow exactly one drop of antigen to fall onto each test sample. Do not stir. Rotate the test card smoothly on the palm of the hand for 8 minutes.** (Or rotate on a mechanical rotator.)
INTERPRETING RESULTS
After 8 minutes rotation, inspect the card in good light. Turn or tilt the card to see whether there is clumping (reactive result). Most test cards include negative and positive control circles for comparison. 1. Non-reactive (no clumping or only slight roughness) - Negative for syphilis 2. Reactive (highly visible clumping) - Positive for syphilis 3. Weakly reactive (minimal clumping) Positive for syphilis NOTE: Weakly reactive can also be more nely granulated and dicult to see than this illustration.
Example Test Card

1
2
3
* Make sure antigen was refrigerated (not frozen) and has not expired. ** Room temperature should be 73 - 85F (22.8 - 29.3C).
112
Assure condentiality in performing the RPR test
If RPR positive:
Determine if the patient and partner have received adequate treatment. If not, treat patient and partner for syphilis with benzathine penicillin. (p.69) If patient has just delivered: Treat newborn with benzathine penicillin. Follow up newborn in 2 weeks.
Counsel on safer sex. Advise to use condoms.
Note: Do not test for cure with a repeat RPR.

The RPR remains positive for some time although the titer goes down.
* RPR = Rapid Plasma Reagin
113
INTEGRATED MANAGEMENT OF ADOLESCENT/ADULT ILLNESS ACUTE CARE RECORDING FORM Name: ____________________________________ Age: ______ Weight: _____ BP:_____ Sex: M F
All patients
All patients
l patients
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TREATMENTS
CLASSIFY Then list
LOOK, LISTEN:
What are the patients problems?_____________________________ _______________________ Pregnant? Acute illness/ Follow-up acute/ Follow-up chronic Quick check emergency signs? Yes No If yes,_______________
ASSESS (circle all signs present)
___Yes ___No DOES THE PATIENT HAVE COUGH OR DIFFICULT BREATHING?
If yes, ASK: For how long? ____ Are you having chest pain? If yes, new? Severe?
Is the patient: Lethargic? Count the breaths in one minute: _____

Fast Very fast breathing? breathing?
Describe it: ________________ Do you have night sweats? Do you smoke? On treatment for: Asthma? Emphysema or chronic bronchitis(COPD)? Heart failure? TB? If no: Have you had previous episodes of cough or difficult breathing? Recurrent episodes If recurrent episodes: Do these episodes wake you up at night or in the early morning? Yes No
Uncomfortable lying down? Look/listen for wheezing. Measure temperature _____ 38C or above If not able to walk unaided or appears ill, also: Count pulse: ______ Measure BP: ______
X CHECK ALL PATIENTS FOR UNDERNUTRITION AND ANAEMIA Look for visible severe wasting. Have you lost weight?
If wasted or weight loss, Old weight______ Diet: Problem:___________________________ Alcohol use If pallor: - Black stools? - Blood in stools? - Epigastric pain? - Blood in urine? If menstruating: Heavy periods?
Loose clothing? If wasted or weight loss: Weight:___kg Wt loss____% MUAC______ Sunken eyes? Oedema to knees? Pitting? Look at palms and conjunctiva for pallor. Severe pallor? Some pallor? If pallor,Count breaths in one minute:___ Breathlessness? Measure haemoglobin:_________ Bleeding gums? Petechiae?
X LOOK IN ALL MOUTHS

___IF
MOUTH OR THROAT PROBLEM

Look in mouth for: White patches If yes, can they be removed? Yes No Ulcer If yes, deep or extensive? Tooth cavities Loss of tooth substance Bleeding from gums Swelling of gums Gum bubble
Do you have pain? If yes, tooth, mouth or throat?
If yes, when swallowing? When hot or cold food? Problems swallowing? Problems chewing? Not able to eat?
Do you have pain? If yes, tooth, mouth or throat?
All patients

Grade pain 0 1 2 3 4 5
If yes, when swallowing? When hot or cold food? Problems swallowing? Problems chewing? Not able to eat? What medications are you taking?
Look in mouth for: White patches If yes, can they be removed? Yes No Ulcer If yes, deep or extensive? Tooth cavities Loss of tooth substance Bleeding from gums Swelling of gums Gum bubble Pus Dark lumps Swelling over jaw Enlarged neck node If tooth pain, does tapping/moving tooth cause pain?
Are you in pain? If yes, where? Are you taking any medications?
Update tetanus toxoid Give mebendazole if due If pregnant, give antenatal care If not pregnant, offer family planning Special prevention for adolescents
Prevention, prophylaxis all patients Women/girls of childbearing age:
All patients
Encourage insecticide-treated bednet Offer family planning Counsel on safer sex Offer HIV testing&counselling Counsel to stop smoking Counsel to reduce or quit alcohol Measure BP If back pain history or risk, teach exercise &correct lifting
___IF FEVER (by history or feels hot or temperature 37.5C or above)
How long have you had a fever? ________ Any other problem? What medications have you taken in the previous
Is the patient: Lethargic? Confused? Agitated? Count the breaths in one minute: _______ Fast breathing?
If fast, is it deep? Check if able to drink Not able to drink Feel for stiff neck Skin rash? Check if able to walk unaided Not able to walk unaided Headache? If yes, for how long?_____ Prolonged Look for apparent cause of fever ______________ Malaria dipstick or smear:
week? If yes, antimalarial? For how long? ______
Decide malaria risk: High Low No Where do you usually live? Recent travel to a malaria area? If woman of childbearing age: Pregnant? Epidemic of malaria occurring? HIV clinical stage 3 or 4?
Look at the patients general condition

Lethargic or unconscious?
___IF DIARRHOEA For how long? _____ Days -If more than 14 days, have you been treated before for persistent diarrhoea? Yes No If yes, with what? When?
Look for sunken eyes. Is the patient:
Is there blood in the stool?
Not able to drink or drinking poorly? Drinking eagerly, thirsty? Pinch the skin of the inside forearm. Does it go back: Very slowly (longer than 2 seconds)? Slowly?
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CLASSIFY Then list TREATMENTS
___ Feel for abdominal tenderness If pain:

Rebound? Guarding? Mass? Absent bowel sounds? Temperature:______ Pulse:______
IF FEMALE PATIENT HAS GENITO-URINARY SX OR LOWER ABDOMINAL PAIN
External exam: Large amount vaginal discharge?

Anal or genital ulcer? Enlarged inguinal lymph node?
What is the problem?_______________________ What medications are you taking? Burning or pain on urination? Increased frequency of urination? Sore in your genital area? Abnormal vaginal discharge? If yes, does it itch? Bleeding on sexual contact? Partner have problem? (If present: Discharge or sore? ) When was last period? If missed a period, possibly pregnant? Are you using contraception? Interested in contraception? If yes, use FP guidelines Very painful menstrual cramps? Periods: very heavy or irregular periods? If yes, new? Days of bleeding:____ Number pads used:______
If able to do bimanual exam, cervical motion tenderness? If burning or pain on urination, percuss flank: Flank
tenderness?
___IF MALE PATIENT HAS GENITO-URINARY SX OR LOWER ABDOMINAL PAIN
What is your problem?_________________________
Discharge from urethra? If yes, for how long?
Burning or pain when you urinate?
Pain in your scrotum? If yes, have you had any trauma there? Do you have sores?
Genital exam: Look for scrotal swelling Feel for tenderness. Look for ulcer Look for urethral discharge Feel for rotated or elevated testis. Feel for abdominal pain If tenderness: Rebound? Guarding? Mass? Absent bowel sounds? Temperature:______ Pulse:______ Look for anogenital sores. If present, are there vesicles? Look for warts Look/feel for enlarged lymph node in inguinal area. If present, is it painful?
___ IF ANOGENITAL ULCER OR SORE Are these new? Recurrent? Vesicles before?
___ IF SKIN PROBLEM OR LUMP Do you have a sore or skin problem or lump?
If yes, where is it?
Are there lesions? If yes, where? How many? Are they infected (red, tender, warm, pus or crusts)? Feel for fluctuance. Are they tender?
Are there lesions? If yes, where? How many? Are they infected (red, tender, warm, pus or crusts)? Feel for fluctuance. Are they tender? Feel for lymph nodes. Look/feel for lumps Are they tender?
___ IF SKIN PROBLEM OR LUMP Do you have a sore or skin problem or lump?
If yes, where is it? Does it itch? Does it hurt?
For how long?
Discharge?
Do other family members have same problem?
PROBLEM Assess for focal neurological problems:
Are you taking any medication?
___IF HEADACHE OR NEUROLOGICAL Weakness in any part of body? Accident or injury involving head? Convulsion? Alcohol use?__________Drug use?___________ Are you taking any medications? Ask family: Patients behaviour changed?
Memory problem? Patient confused? If confused, when did it start? Disoriented to place or time? If headache: For how long? One-sided? Visual defects? Prior diagnosis migraine? Vomiting? In HIV patient, new unusual headache?
Test strength Look at face: flaccid on one side? Problem walking? Problem talking? Problem moving eyes? Flaccid arms or legs? If yes, loss of strength? Feel for stiff neck Measure BP:_____ Is patient confused? If patient reports weakness, test strength. If headache, feel for sinus tenderness
___IF MENTAL PROBLEM, LOOKS DEPRESSED OR ANXIOUS, SAD, FATIGUE, RECURRENT MULTIPLE PROBLEMS, HEAVY ALCOHOL USE
Does patient appear: Agitated? Depressed? Is patient confused? Does the patient express bizarre thoughts? If yes,
Disoriented to time or place?
How are you feeling? (listen without interrupting) Do you feel sad, depressed? Lost interest/pleasure? Less energy than usual? If any of these 3 present, ask for depression symptoms:
Does the patient express incredible beliefs (delusions) or sees or hears things others cannot (hallucinations)? Is the patient intoxicated with alcohol or on drugs which might cause these problems?
Disturbed sleep Appetite loss (or increase) Poor concentration Moves slowly Decreased libido Loss of self-confidence or esteem Thoughts of suicide or death Guilty feelings
Does patient have a tremor?
Have you had bad news? Do you drink alcohol? If yes:
If suicidal thoughts, assess the risk: - Do you have a plan? a tremor? Does patient have
117
Drinks/week over last 3 months:____ Drunk more than 2 times in past year?
- Determine if patient has the means - Find out if there is a fixed timeframe - Is the family aware? - Has there been an attempt? How? Potentially lethal?
Acute Care Acronyms

AIDS ARV ART BP BV CD4 Cm COPD EPI GC GI GYN Hg HIV IM IMAI IMPAC INH IU IUD IV Kg Mcg MD MDT Mg Ml Mm MO MUAC NG NPO ORS PCN PGL PID PMTCT RF RHD RPR RPM STI Td TB TT ZDV Acquired Immunodeciency Syndrome Antiretroviral Antiretroviral Therapy Blood Pressure Bacterial Vaginosis Count of the lymphocytes with a CD4 surface marker per cubic millimetre of blood Centimetre Chronic Obstructive Pulmonary Disease Expanded Programme on Immunization Gonorrhoea Gastrointestinal Gynaecological Mercury Human Immunodeciency Virus Intramuscular Integrated Management of Adolescent and Adult Illness Integrated Management of Pregnancy and Childbirth Isoniazid International Units Intrauterine Device Intravenous Kilogram Microgram Medical Doctor Multi-Drug Therapy (for leprosy) Milligram Millilitre Millimetre Medical Ocer Middle Upper Arm Circumference Naso-gastric Nothing per os = nothing by mouth Oral Rehydration Solution Penicillin Persistent Generalised Lymphadenopathy Pelvic Inammatory Disease Prevention of Mother to Child Transmission (of HIV) Rheumatic Fever Rheumatic Heart Disease Rapid Plasma Reagent test for syphilis Rotations per Minute Sexually Transmitted Infection Tetanus Diphtheria Tuberculosis Tetanus Toxoid Zidovudine
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WHO/CDS/IMAI/2004.

INTEGRATED MANAGEMENT OF ADOLESCENT AND ADULT ILLNESS

Integrated Management: Acute Care

Assess Acute Illness

Consider HIVRelated Illness

Advise and Counsel

Prevention: Screening and Prophylaxis

Follow-up Care for Acute Illness

Link with Chronic HIV Care

Consider HIV-related Illness Prevention: Routine Screening and Prophylaxis

Follow-up Care for Acute Illness

Advise and Counsel

Recording Form/Desk Aid

Steps to Use the IMAI Acute Care Module

Consider HIVRelated Illness

Follow-up Care for Acute Illness

Quick Check for Emergency Care

Assess Acute Illness/ Classify/Identify Treatments

Quick Check for Emergency Signs

THEN ASSESS: CIRCULATION (SHOCK)

Measure BP and temperature

If severe abdominal pain: Is abdomen hard?

Check BP, pulse, temperature

If neck pain or severe headache: Has there been any trauma?

Check BP Ask patient to move neckdo not passively move

If trauma, use the Quick Check guidelines.

FEVER from LIFE-THREATENING CAUSE

Any sign present measure temperature, BP

Also consider neglected trauma with infectionsee Quick Check guidelines.

If no emergency signs, proceed immediately to

Assess Acute Illness/ Classify/Identify Treatments

Assess Acute Illness

In all patients: Do you have cough or dicult breathing?

LOOK AND LISTEN

Classify in all with cough

FAST BREATHING IS:

VERY FAST BREATHING IS:

POSSIBLE CHRONIC LUNG OR HEART PROBLEM

Insucient signs for the above classications

NO PNEUMONIA COUGH/COLD, OR BRONCHITIS

Check all patients for undernutrition and anaemia

Use this table if visible wasting or weight loss SIGNS:

SIGNIFICANT WEIGHT LOSS

* Weight loss < 5%

NO SIGNIFICANT WEIGHT LOSS

Use this table if pallor

Consider HIV-related illness (p. 54)

If patient has white or red patches

If sore throat without mouth problem

If patient has white or red patches SIGNS:

Pain or diculty swallowing

OESOPHAGEAL THRUSH ORAL THRUSH

ORAL (HAIRY) LEUKOPLAKIA

Use this table if sore throat without mouth problem

Enlarged lymph node on neck and White exudate on throat

STREPTOCOCCAL SORE THROAT

Only 1 or no signs in the above row present

NON-STREP SORE THROAT

Use this table if mouth ulcer or gum problem: SIGNS:

Ulcers of mouth or gums

Use this table if tooth problem or jaw pain or swelling:

In all patients, ask: Are you in pain?

In all patients, ask: Are you taking any medications?